MEDICARE: ACTIVE ANGELS 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	License Number State
1	251E00000X	Home Health Agency	LCO762551	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0008897	OTHER	MO	SSBG GR

General Provider Information

NPI Number	:	1437274073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE ANGELS IN HOME HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	9191 W FLORISSANT AVE
Second Line	:	SUITE 215
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-1424
Country	:	US
Telephone Number	:	314-524-4200
Fax Number	:	314-524-4203

Provider Business Practice Location Address
First Line	:	9191 W FLORISSANT AVE
Second Line	:	SUITE 215
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-1424
Country	:	US
Telephone Number	:	314-524-4200
Fax Number	:	314-524-4203

Authorized Official
Title or Position	:	DIRECTOR(OWNER)
Name	:	MS. SHARON LORETTA PETERS
Credential	:	STATE CERTIFIED
Telephone Number	:	314-524-4200

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	08/02/2013

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