MEDICARE: HERITAGE CDS 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	:	1588017818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE CDS LLC

Provider Business Mailing Address
First Line	:	PO BOX 5990
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63134-0990
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4433 WOODSON RD STE 101
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63134-3713
Country	:	US
Telephone Number	:	314-266-8409
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JESSICA BYRD
Credential	:
Telephone Number	:	314-266-8409

Provider Enumeration Date	:	07/21/2016
Last Update Date	:	07/21/2016

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