MEDICARE: ALTERNATIVE CHOICES CONSUMER DIRECTED SVC 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	B00436508	MO

General Provider Information

NPI Number	:	1548537590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTERNATIVE CHOICES CONSUMER DIRECTED SVC LLC

Provider Business Mailing Address
First Line	:	1920 GREEN VALLEY DR
Second Line	:	1920 GREEN VALLEY DRIVE
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-3205
Country	:	US
Telephone Number	:	314-761-3838
Fax Number	:	314-869-3393

Provider Business Practice Location Address
First Line	:	1920 GREEN VALLEY DR
Second Line	:	1920 GREEN VALLEY DRIVE
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-3205
Country	:	US
Telephone Number	:	314-761-3838
Fax Number	:	314-869-3393

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MS. JACQUELINE LAKALE PENNINGTON
Credential	:	ASSOCIATE DEGREE
Telephone Number	:	314-761-3838

Provider Enumeration Date	:	11/18/2011
Last Update Date	:	05/02/2012

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