MEDICARE: EXCELSIOR HEALTHCARE II 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		MO

General Provider Information

NPI Number	:	1730692997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELSIOR HEALTHCARE II LLC

Provider Business Mailing Address
First Line	:	4841 LEXINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-2013
Country	:	US
Telephone Number	:	314-267-4004
Fax Number	:	314-899-9949

Provider Business Practice Location Address
First Line	:	4841 LEXINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-2013
Country	:	US
Telephone Number	:	314-267-4004
Fax Number	:	314-899-9949

Authorized Official
Title or Position	:	CEO
Name	:	MR. MICHAEL Q BOYD
Credential	:
Telephone Number	:	314-267-4004

Provider Enumeration Date	:	11/09/2017
Last Update Date	:	11/09/2017

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