Provider Demographics
NPI:1417558412
Name:AVI MARIE VITALITY HOME CARE LLC
Entity type:Organization
Organization Name:AVI MARIE VITALITY HOME CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:TAREKA
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-596-8919
Mailing Address - Street 1:7777 BONHOMME STE #1827
Mailing Address - Street 2:8321 MCLARAN AVE
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1129
Mailing Address - Country:US
Mailing Address - Phone:314-764-5020
Mailing Address - Fax:636-237-8304
Practice Address - Street 1:7777 BONHOMME AVE STE 1827
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-1911
Practice Address - Country:US
Practice Address - Phone:314-764-5020
Practice Address - Fax:636-237-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-05
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care