MEDICARE: WALLACE FAMILY IN HOME HEALTH 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	347C00000X	Private Vehicle
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1841698388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE FAMILY IN HOME HEALTH LLC

Provider Business Mailing Address
First Line	:	6530 JULIAN AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63133-1410
Country	:	US
Telephone Number	:	314-713-1105
Fax Number	:	314-754-9969

Provider Business Practice Location Address
First Line	:	3937 PARK AVE
Second Line	:	PARK WAREHOUSE
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2317
Country	:	US
Telephone Number	:	314-713-1105
Fax Number	:	314-754-9969

Authorized Official
Title or Position	:	CEO
Name	:	BRITTANY JACKSON
Credential	:
Telephone Number	:	314-713-1105

Provider Enumeration Date	:	12/16/2014
Last Update Date	:	12/16/2014

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