MEDICARE: BLUE HAYVEN IN-HOME HEALTH CARE

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	320700000X	Physical Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1922335926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE HAYVEN IN-HOME HEALTH CARE

Provider Business Mailing Address
First Line	:	11553 WITHERSFIELD DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1152
Country	:	US
Telephone Number	:	314-395-6121
Fax Number	:	314-395-6121

Provider Business Practice Location Address
First Line	:	11553 WITHERSFIELD DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1152
Country	:	US
Telephone Number	:	314-395-6121
Fax Number	:	314-395-6121

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. NICOLE BROCK-WILLIAMS
Credential	:
Telephone Number	:	314-395-6121

Provider Enumeration Date	:	11/11/2009
Last Update Date	:	11/11/2009

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