Provider Demographics
NPI:1194196469
Name:PERSONAL HOME CARE CDS, LLC
Entity Type:Organization
Organization Name:PERSONAL HOME CARE CDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-664-1100
Mailing Address - Street 1:100 S MARKET ST
Mailing Address - Street 2:STE 500
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63102
Mailing Address - Country:US
Mailing Address - Phone:314-797-5066
Mailing Address - Fax:314-797-5001
Practice Address - Street 1:100 S MARKET ST
Practice Address - Street 2:STE 500
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101
Practice Address - Country:US
Practice Address - Phone:314-797-5066
Practice Address - Fax:314-797-5001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3747P1801XMedicaid