Provider Demographics
NPI:1306060488
Name:PHILLIPS PROFESSIONAL HOME HEALTH SERVICE
Entity type:Organization
Organization Name:PHILLIPS PROFESSIONAL HOME HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PEARL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-423-9596
Mailing Address - Street 1:8456A PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1055
Mailing Address - Country:US
Mailing Address - Phone:314-423-9596
Mailing Address - Fax:314-426-1678
Practice Address - Street 1:8456A PAGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-1055
Practice Address - Country:US
Practice Address - Phone:314-423-9596
Practice Address - Fax:314-426-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0003114251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268875609Medicaid
MO288874605Medicaid