Provider Demographics
NPI:1255588265
Name:HOME SWEET HOME SUPPORTIVE LIVING LLC
Entity type:Organization
Organization Name:HOME SWEET HOME SUPPORTIVE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:T
Authorized Official - Middle Name:
Authorized Official - Last Name:VALIANT
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE-BSN
Authorized Official - Phone:314-458-8272
Mailing Address - Street 1:PO BOX 38085
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138
Mailing Address - Country:US
Mailing Address - Phone:314-458-8272
Mailing Address - Fax:
Practice Address - Street 1:100 NORTHWEST POINT BLVD.
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007
Practice Address - Country:US
Practice Address - Phone:314-458-8272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC0914417320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities