Provider Demographics
NPI:1992460273
Name:SELF RELIANT HOMECARE LLC
Entity type:Organization
Organization Name:SELF RELIANT HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-386-9340
Mailing Address - Street 1:9432 LACKLAND RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-3601
Mailing Address - Country:US
Mailing Address - Phone:314-764-1647
Mailing Address - Fax:
Practice Address - Street 1:9432 LACKLAND RD
Practice Address - Street 2:
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-3601
Practice Address - Country:US
Practice Address - Phone:314-764-1647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care