Provider Demographics
NPI:1992783732
Name:PROFESSIONAL HOME HEALTH AGENCY LLC
Entity type:Organization
Organization Name:PROFESSIONAL HOME HEALTH AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MALIK
Authorized Official - Middle Name:S
Authorized Official - Last Name:KARIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-946-5051
Mailing Address - Street 1:2730 S SAINT PETERS PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5677
Mailing Address - Country:US
Mailing Address - Phone:636-946-5051
Mailing Address - Fax:636-946-5039
Practice Address - Street 1:2730 S SAINT PETERS PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-5677
Practice Address - Country:US
Practice Address - Phone:636-946-5051
Practice Address - Fax:636-946-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO267593251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO586221509Medicaid
MO586221509Medicaid