Provider Demographics
NPI:1295087195
Name:AGING WELL HEALTH CARE, LLC
Entity type:Organization
Organization Name:AGING WELL HEALTH CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURSAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-726-5600
Mailing Address - Street 1:7212 BALSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3001
Mailing Address - Country:US
Mailing Address - Phone:314-726-5600
Mailing Address - Fax:314-754-9317
Practice Address - Street 1:540 REGENCY CTR
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4658
Practice Address - Country:US
Practice Address - Phone:618-344-8800
Practice Address - Fax:618-344-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010588251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health