MEDICARE: PROACTIVE HOME CARE MISSOURI

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1932758125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE HOME CARE MISSOURI

Provider Business Mailing Address
First Line	:	104B W MOUNT VERNON BLVD
Second Line	:
City	:	MOUNT VERNON
State	:	MO
Zip	:	65712-1936
Country	:	US
Telephone Number	:	417-850-2013
Fax Number	:	417-855-2242

Provider Business Practice Location Address
First Line	:	104B W MOUNT VERNON BLVD
Second Line	:
City	:	MOUNT VERNON
State	:	MO
Zip	:	65712-1936
Country	:	US
Telephone Number	:	417-850-2013
Fax Number	:	417-855-2242

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. SADIE K MUSICK
Credential	:
Telephone Number	:	417-380-3829

Provider Enumeration Date	:	09/10/2019
Last Update Date	:	09/10/2019

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