MEDICARE: EXTENDED COMFORT CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1104593672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED COMFORT CARE LLC

Provider Business Mailing Address
First Line	:	6535 JESSE JACKSON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-5706
Country	:	US
Telephone Number	:	314-224-1293
Fax Number	:

Provider Business Practice Location Address
First Line	:	6535 JESSE JACKSON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-5706
Country	:	US
Telephone Number	:	314-224-1293
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHEONTAY DAVIS
Credential	:
Telephone Number	:	314-224-1293

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	08/24/2021

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Directions to “EXTENDED COMFORT CARE LLC ” Practice Location

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