FOUNDATION CARE LLC

Provider Demographics

• NPI: 1205831963
• Name: FOUNDATION CARE LLC
• Entity Type: Organization
• Organization Name: FOUNDATION CARE LLC
• Other - Org Name: FOUNDATION CARE LLC
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: PRESIDENT, DIRECTOR
• Authorized Official - First Name: JESSICA
• Authorized Official - Middle Name: DAWN
• Authorized Official - Last Name: CICCOLELLA-KAHL
• Authorized Official - Phone: 800-511-5144
• Mailing Address - Street 1: PO BOX 955362
• Mailing Address - City: SAINT LOUIS
• Mailing Address - State: MO
• Mailing Address - Zip Code: 63195-5362
• Mailing Address - Country: US
• Mailing Address - Phone: 855-422-2742
• Mailing Address - Fax: 866-834-8523
• Practice Address - Street 1: 4010 WEDGEWAY CT
• Practice Address - City: EARTH CITY
• Practice Address - State: MO
• Practice Address - Zip Code: 63045
• Practice Address - Country: US
• Practice Address - Phone: 877-291-1122
• Practice Address - Fax: 877-291-1155
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-06-17
• Last Update Date: 2024-01-31

Provider Licenses

State	License ID	Taxonomies
		251F00000X, 3336H0001X
MO	2004013283	332B00000X, 333600000X
IN	64002443A	3336C0003X
FL	PH20916	3336C0003X
CT	PCN.0000657	3336C0003X
ID	46426MS	3336C0003X
LA	PHY2018	3336C0003X
DE	A9-0002061	3336C0003X
IL	054.020540	3336C0003X
DC	NRX1100278	3336C0003X
CO	OSP,0005639	3336C0003X
MD	P07621	3336C0003X
AL	112787	3336C0003X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336C0003X	Suppliers	Pharmacy	Community/Retail Pharmacy
No	251F00000X	Agencies	Home Infusion
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
Yes	333600000X	Suppliers	Pharmacy
No	3336H0001X	Suppliers	Pharmacy	Home Infusion Therapy Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MO	606143006	Medicaid
	2172192	Other	PK
IL	=========-63045-01	Medicaid
IA	0582205	Medicaid
ID	807778400	Medicaid
AZ	236336	Medicaid
MN	829686300	Medicaid
AL	PH587MO	Medicaid
MD	004896800	Medicaid
PA	101146648 0001	Medicaid
AK	154542407	Medicaid
KS	200278160A	Medicaid
MI	2635564	Medicaid
MO	606143006	Medicaid
IL	=========-63045-01	Medicaid
NJ	0062618	Medicaid
IN	200495160A	Medicaid
NH	30703404	Medicaid
WY	1202197 00	Medicaid
IL	=========-63045-01	Medicaid
NJ	0062618	Medicaid
MD	004896800	Medicaid