Provider Demographics
NPI:1104513415
Name:IDALIA BLUE'S HOME HEALTH LLC
Entity type:Organization
Organization Name:IDALIA BLUE'S HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-328-9664
Mailing Address - Street 1:6221 GREER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-5617
Mailing Address - Country:US
Mailing Address - Phone:636-328-9664
Mailing Address - Fax:
Practice Address - Street 1:10174 W FLORISSANT AVE STE 319
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-2104
Practice Address - Country:US
Practice Address - Phone:636-328-9664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-18
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care