Provider Demographics
NPI:1720417348
Name:MISSOURI IN HOME SERVICES - CDS
Entity Type:Organization
Organization Name:MISSOURI IN HOME SERVICES - CDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:HENCE
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:FORLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-524-3958
Mailing Address - Street 1:6746 PAGE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63133-1616
Mailing Address - Country:US
Mailing Address - Phone:314-524-3958
Mailing Address - Fax:314-524-3959
Practice Address - Street 1:6746 PAGE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-1616
Practice Address - Country:US
Practice Address - Phone:314-524-3958
Practice Address - Fax:314-524-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0012999Medicaid