MEDICARE: MULBERRY STREET TBI, 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1851639645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MULBERRY STREET TBI, LLC

Provider Business Mailing Address
First Line	:	1517 SW STATE ROUTE 7
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-3944
Country	:	US
Telephone Number	:	816-224-2000
Fax Number	:	816-224-2006

Provider Business Practice Location Address
First Line	:	1517 SW STATE ROUTE 7
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-3944
Country	:	US
Telephone Number	:	816-224-2000
Fax Number	:	816-224-2006

Authorized Official
Title or Position	:	CO-DIRECTOR
Name	:	MR. JOSHUA AARON MACK
Credential	:
Telephone Number	:	816-224-2000

Provider Enumeration Date	:	01/29/2013
Last Update Date	:	01/29/2013

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