MEDICARE: HEART OF GOLD IN HOME HEALTH SERVICE, 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		MO
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1396030623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART OF GOLD IN HOME HEALTH SERVICE, LLC

Provider Business Mailing Address
First Line	:	50 BLACK JACK CT
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-7101
Country	:	US
Telephone Number	:	314-653-0500
Fax Number	:	314-653-0545

Provider Business Practice Location Address
First Line	:	50 BLACK JACK CT
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-7101
Country	:	US
Telephone Number	:	314-653-0500
Fax Number	:	314-653-0545

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. SHARISE WILLIAMS
Credential	:	RN
Telephone Number	:	314-495-1854

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	08/09/2011

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