MEDICARE: IDALIA BLUE'S HOME HEALTH 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

General Provider Information

NPI Number	:	1780450122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDALIA BLUE'S HOME HEALTH II LLC

Provider Business Mailing Address
First Line	:	10174 W FLORISSANT AVE # 319
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-2104
Country	:	US
Telephone Number	:	636-328-9664
Fax Number	:

Provider Business Practice Location Address
First Line	:	10174 W FLORISSANT AVE # 319
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-2104
Country	:	US
Telephone Number	:	636-328-9664
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	TRICIA COLEMAN
Credential	:
Telephone Number	:	636-328-9664

Provider Enumeration Date	:	11/28/2023
Last Update Date	:	02/05/2024

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