Provider Demographics
NPI:1184497968
Name:BOUNTIFUL BENEVOLENCE AT HOME WE CARE
Entity type:Organization
Organization Name:BOUNTIFUL BENEVOLENCE AT HOME WE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TYREN
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:636-395-2361
Mailing Address - Street 1:500 ARBOR LANE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7682
Mailing Address - Country:US
Mailing Address - Phone:636-395-2361
Mailing Address - Fax:
Practice Address - Street 1:1000 MID RIVERS MALL DR STE B2
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2171
Practice Address - Country:US
Practice Address - Phone:636-395-2361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health