Provider Demographics
NPI:1366216897
Name:MRS OCTAVIA HOME HEALTH CARE LLC
Entity type:Organization
Organization Name:MRS OCTAVIA HOME HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-226-4500
Mailing Address - Street 1:1516 GOODFELLOW BLVD UNIT-A
Mailing Address - Street 2:1516 GOODFELLOW BLVD UNIT-A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112
Mailing Address - Country:US
Mailing Address - Phone:314-652-4209
Mailing Address - Fax:
Practice Address - Street 1:1516 GOODFELLOW BLVD UNIT-A
Practice Address - Street 2:1516 GOODFELLOW BLVD APT-A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112
Practice Address - Country:US
Practice Address - Phone:314-226-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-15
Last Update Date:2023-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty