Provider Demographics
NPI:1811420680
Name:HOME FOREVER PROFESSIONAL CARE LLC
Entity Type:Organization
Organization Name:HOME FOREVER PROFESSIONAL CARE LLC
Other - Org Name:HOME FOREVER PROFESSIONAL CARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ETIENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-696-2219
Mailing Address - Street 1:3621 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-3509
Mailing Address - Country:US
Mailing Address - Phone:314-550-2990
Mailing Address - Fax:314-696-2212
Practice Address - Street 1:3621 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3509
Practice Address - Country:US
Practice Address - Phone:314-550-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health