Provider Demographics
NPI:1720468770
Name:GRANDMA'S ANGELS CONSUMER DIRECTED SERVICES LLC
Entity type:Organization
Organization Name:GRANDMA'S ANGELS CONSUMER DIRECTED SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MOZZIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-435-0009
Mailing Address - Street 1:13132 NORTHVIEW HEIGHTS CT
Mailing Address - Street 2:
Mailing Address - City:BLACK JACK
Mailing Address - State:MO
Mailing Address - Zip Code:63033-4564
Mailing Address - Country:US
Mailing Address - Phone:314-435-0009
Mailing Address - Fax:
Practice Address - Street 1:13132 NORTHVIEW HEIGHTS CT
Practice Address - Street 2:
Practice Address - City:BLACK JACK
Practice Address - State:MO
Practice Address - Zip Code:63033-4564
Practice Address - Country:US
Practice Address - Phone:314-435-0009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO253Z00000X251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health