MEDICARE: AVI MARIE VITALITY HOME 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1417558412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVI MARIE VITALITY HOME CARE LLC

Provider Business Mailing Address
First Line	:	7777 BONHOMME STE #1827
Second Line	:	8321 MCLARAN AVE
City	:	ST LOUIS
State	:	MO
Zip	:	63136-1129
Country	:	US
Telephone Number	:	314-764-5020
Fax Number	:	636-237-8304

Provider Business Practice Location Address
First Line	:	7777 BONHOMME AVE STE 1827
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63105-1911
Country	:	US
Telephone Number	:	314-764-5020
Fax Number	:	636-237-8304

Authorized Official
Title or Position	:	OWNER
Name	:	MELODY TAREKA MOORE
Credential	:
Telephone Number	:	770-596-8919

Provider Enumeration Date	:	11/05/2020
Last Update Date	:	07/23/2024

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