Provider Demographics
NPI:1164971933
Name:417 HOME CARE LLC
Entity Type:Organization
Organization Name:417 HOME CARE LLC
Other - Org Name:HAVEN HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-496-5958
Mailing Address - Street 1:850 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8033
Mailing Address - Country:US
Mailing Address - Phone:417-581-1234
Mailing Address - Fax:888-844-7031
Practice Address - Street 1:850 N 25TH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8033
Practice Address - Country:US
Practice Address - Phone:417-581-1234
Practice Address - Fax:888-844-7031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty