Provider Demographics
NPI:1699277749
Name:SUPPORT FOR INDEPENDENCE
Entity type:Organization
Organization Name:SUPPORT FOR INDEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:UNIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-504-1459
Mailing Address - Street 1:1419 DEVONSHIRE COUNTY DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4349
Mailing Address - Country:US
Mailing Address - Phone:314-504-1459
Mailing Address - Fax:
Practice Address - Street 1:1419 DEVONSHIRE COUNTY DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4349
Practice Address - Country:US
Practice Address - Phone:314-504-1459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========Medicaid