MEDICARE: JOHNSON'S PHENOMENAL HANDS 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	374U00000X	Home Health Aide
2	376J00000X	Homemaker

General Provider Information

NPI Number	:	1255096194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON'S PHENOMENAL HANDS LLC

Provider Business Mailing Address
First Line	:	9021 RIVERVIEW DR # 310
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63137-2424
Country	:	US
Telephone Number	:	314-396-0043
Fax Number	:

Provider Business Practice Location Address
First Line	:	9021 RIVERVIEW DR # 310
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63137-2424
Country	:	US
Telephone Number	:	314-396-0043
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. JOANN RENA JOHNSON
Credential	:
Telephone Number	:	314-471-1441

Provider Enumeration Date	:	11/04/2021
Last Update Date	:	11/04/2021

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