Provider Demographics
NPI:1083356638
Name:A HEART FULL OF LOVE HOME HEALTH LLC
Entity Type:Organization
Organization Name:A HEART FULL OF LOVE HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:314-269-6907
Mailing Address - Street 1:10000 N 31ST AVE STE D304B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-9582
Mailing Address - Country:US
Mailing Address - Phone:314-269-6907
Mailing Address - Fax:
Practice Address - Street 1:10000 N 31ST AVE STE D304B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-9582
Practice Address - Country:US
Practice Address - Phone:314-269-6907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO489783172Medicaid