Provider Demographics
NPI:1710274089
Name:KINGDOM HEARTS IN-HOME LLC
Entity Type:Organization
Organization Name:KINGDOM HEARTS IN-HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-680-1976
Mailing Address - Street 1:320 BROOKES DR STE 203
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-2740
Mailing Address - Country:US
Mailing Address - Phone:314-680-1976
Mailing Address - Fax:
Practice Address - Street 1:320 BROOKES DR STE 203
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2740
Practice Address - Country:US
Practice Address - Phone:314-680-1976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health