MEDICARE: ABUNDANTLY ANGELS CONSUMER DIRECTED 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

General Provider Information

NPI Number	:	1790318327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANTLY ANGELS CONSUMER DIRECTED SERVICES LLC

Provider Business Mailing Address
First Line	:	2705 SAINT PETERS HOWELL RD STE L
Second Line	:
City	:	SAINT PETERS
State	:	MO
Zip	:	63376-2821
Country	:	US
Telephone Number	:	314-585-3074
Fax Number	:	363-222-9585

Provider Business Practice Location Address
First Line	:	2705 SAINT PETERS HOWELL RD STE L
Second Line	:
City	:	SAINT PETERS
State	:	MO
Zip	:	63376-2821
Country	:	US
Telephone Number	:	314-585-3074
Fax Number	:	363-222-9585

Authorized Official
Title or Position	:	CEO
Name	:	MS. ANGELA MARLETT
Credential	:
Telephone Number	:	636-970-9848

Provider Enumeration Date	:	02/21/2020
Last Update Date	:	02/21/2020

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