Provider Demographics
NPI:1528598406
Name:QUEEN HOME CARE, LLC
Entity Type:Organization
Organization Name:QUEEN HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAHMOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOSARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-303-0433
Mailing Address - Street 1:4333 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4333 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2137
Practice Address - Country:US
Practice Address - Phone:314-303-0433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO23380446OtherBUSINESS TAX REGISTRATION - MO DEPARTMENT OF REVENUE