MEDICARE: HOMEPLACE HEALTHCARE 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	253Z00000X	In Home Supportive Care Agency
2	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1336700616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOMEPLACE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	13675 EVERGREEN GLEN DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-4273
Country	:	US
Telephone Number	:	410-574-4955
Fax Number	:

Provider Business Practice Location Address
First Line	:	13675 EVERGREEN GLEN DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-4273
Country	:	US
Telephone Number	:	410-574-4955
Fax Number	:

Authorized Official
Title or Position	:	CO-DIRECTOR
Name	:	OGHENERO OLOMUKORO
Credential	:
Telephone Number	:	410-574-4955

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	06/26/2019

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