Provider Demographics
NPI:1750719563
Name:STAT J IN HOME CARE LLC
Entity type:Organization
Organization Name:STAT J IN HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TWANIECE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-695-5113
Mailing Address - Street 1:12942 COVINGTON GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1528
Mailing Address - Country:US
Mailing Address - Phone:314-695-5113
Mailing Address - Fax:314-932-5009
Practice Address - Street 1:12942 COVINGTON GARDENS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1528
Practice Address - Country:US
Practice Address - Phone:314-695-5113
Practice Address - Fax:314-932-5009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC1302938251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health