=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427833862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENNOVY HEALTH AT HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2023
-----------------------------------------------------
Last Update Date | 08/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12645 OLIVE BLVD STE 232
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-6692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-875-3772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7041 BELLINGHAM CIR
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-6963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-875-3772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | RAQUEL N JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 636-875-3772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------