Provider Demographics
NPI:1871113670
Name:HEALING HEART DIRECT SERVICE CONSUMER LLC
Entity type:Organization
Organization Name:HEALING HEART DIRECT SERVICE CONSUMER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMT
Authorized Official - Phone:314-224-9426
Mailing Address - Street 1:52 ARBOR VILLAGE CT APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63135-2975
Mailing Address - Country:US
Mailing Address - Phone:314-224-9426
Mailing Address - Fax:
Practice Address - Street 1:52 ARBOR VILLAGE CT APT A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63135-2975
Practice Address - Country:US
Practice Address - Phone:314-224-9426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health