Provider Demographics
NPI:1134257181
Name:FOUR SEASONS IN HOME SERVICES,LLC
Entity type:Organization
Organization Name:FOUR SEASONS IN HOME SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DESTEFANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-2600
Mailing Address - Street 1:908 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1453
Mailing Address - Country:US
Mailing Address - Phone:660-826-2600
Mailing Address - Fax:660-826-0021
Practice Address - Street 1:908 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1453
Practice Address - Country:US
Practice Address - Phone:660-826-2600
Practice Address - Fax:660-826-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO855305801Medicaid