Provider Demographics
NPI:1639172455
Name:COMFORT CARE HOME HEALTH AGENCY, INC
Entity Type:Organization
Organization Name:COMFORT CARE HOME HEALTH AGENCY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLIN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:573-996-3524
Mailing Address - Street 1:1415 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-1016
Mailing Address - Country:US
Mailing Address - Phone:573-996-3524
Mailing Address - Fax:573-996-4531
Practice Address - Street 1:1415 WALNUT ST
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1016
Practice Address - Country:US
Practice Address - Phone:573-996-3524
Practice Address - Fax:573-996-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO546-6251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO588583500Medicaid
MO112511OtherBC/BS NUMBER
MO267522Medicare ID - Type Unspecified