Provider Demographics
NPI:1689081739
Name:FREEDOM CUSTOMIZED CARE LLC
Entity Type:Organization
Organization Name:FREEDOM CUSTOMIZED CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:KNUCKLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-494-1560
Mailing Address - Street 1:6614 W FLORISSANT AVE
Mailing Address - Street 2:UNIT 3A
Mailing Address - City:JENNINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-3646
Mailing Address - Country:US
Mailing Address - Phone:314-494-1560
Mailing Address - Fax:
Practice Address - Street 1:6614 W FLORISSANT AVE
Practice Address - Street 2:UNIT 3A
Practice Address - City:JENNINGS
Practice Address - State:MO
Practice Address - Zip Code:63136-3646
Practice Address - Country:US
Practice Address - Phone:314-494-1560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care