=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841735602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME FOREVER PROFESSIONAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2017
-----------------------------------------------------
Last Update Date | 01/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3621 LOUISIANA AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63118-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-550-2990
-----------------------------------------------------
Fax | 314-682-6047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3621 LOUISIANA AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63118-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-550-2990
-----------------------------------------------------
Fax | 314-682-6047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ETIENNA COLEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-682-6047
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------