Provider Demographics
NPI:1417587437
Name:EXECUTIVE HOME HEALTH
Entity Type:Organization
Organization Name:EXECUTIVE HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARQUITA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-501-2227
Mailing Address - Street 1:8422 OAK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-1034
Mailing Address - Country:US
Mailing Address - Phone:314-599-6062
Mailing Address - Fax:
Practice Address - Street 1:8422 OAK DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-1034
Practice Address - Country:US
Practice Address - Phone:314-599-6062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health