MEDICARE: BLUE HAYVEN IN HOME HEALTH CARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	302R00000X	Health Maintenance Organization	MO
2	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
3	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1336439694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE HAYVEN IN HOME HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	11553 WITHERSFIELD DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1152
Country	:	US
Telephone Number	:	314-440-8087
Fax Number	:

Provider Business Practice Location Address
First Line	:	11553 WITHERSFIELD DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1152
Country	:	US
Telephone Number	:	314-440-8087
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	NICOLE M BROCK-WILLIAMS
Credential	:
Telephone Number	:	314-440-8087

Provider Enumeration Date	:	04/07/2011
Last Update Date	:	04/07/2011

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