MEDICARE: MISSOURI IN HOME SERVICES - CDS

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720417348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI IN HOME SERVICES - CDS

Provider Business Mailing Address
First Line	:	6746 PAGE AVE STE 200
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1616
Country	:	US
Telephone Number	:	314-524-3958
Fax Number	:	314-524-3959

Provider Business Practice Location Address
First Line	:	6746 PAGE AVE STE 200
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1616
Country	:	US
Telephone Number	:	314-524-3958
Fax Number	:	314-524-3959

Authorized Official
Title or Position	:	OWNER
Name	:	MS. HENCE MONIQUE FORLAND
Credential	:
Telephone Number	:	314-524-3958

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	12/30/2021

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