MEDICARE: DTA HOME HEALTH SERVICES 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	:	1790220796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DTA HOME HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	1822 DUNNIDEER DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-3004
Country	:	US
Telephone Number	:	314-680-0281
Fax Number	:

Provider Business Practice Location Address
First Line	:	1822 DUNNIDEER DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-3004
Country	:	US
Telephone Number	:	314-680-0281
Fax Number	:	314-388-1632

Authorized Official
Title or Position	:	OWNER
Name	:	ELONA DANAIL BEVLY
Credential	:
Telephone Number	:	314-680-0281

Provider Enumeration Date	:	12/29/2016
Last Update Date	:	12/29/2016

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