=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538607874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLIES ANGELS CARE LLC CDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2017
-----------------------------------------------------
Last Update Date | 02/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10220 EDGEFIELD DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63136-5622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-869-4077
-----------------------------------------------------
Fax | 314-869-4077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10220 EDGEFIELD DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63136-5622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-869-4077
-----------------------------------------------------
Fax | 314-869-4077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | TEQUILA JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-437-5744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------