Provider Demographics
NPI:1841698388
Name:WALLACE FAMILY IN HOME HEALTH LLC
Entity type:Organization
Organization Name:WALLACE FAMILY IN HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-713-1105
Mailing Address - Street 1:6530 JULIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63133-1410
Mailing Address - Country:US
Mailing Address - Phone:314-713-1105
Mailing Address - Fax:314-754-9969
Practice Address - Street 1:3937 PARK AVE
Practice Address - Street 2:PARK WAREHOUSE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2317
Practice Address - Country:US
Practice Address - Phone:314-713-1105
Practice Address - Fax:314-754-9969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle