1033104039 NPI number — HOME HEALTH AGENCY ILLINOIS, LLC

Table of content: (NPI 1033104039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033104039 NPI number — HOME HEALTH AGENCY ILLINOIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOME HEALTH AGENCY ILLINOIS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OMNI HOME CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033104039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37115-5033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-712-2250
Provider Business Mailing Address Fax Number:
615-577-0081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19146 88TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOKENA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60448-8135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-532-4466
Provider Business Practice Location Address Fax Number:
708-532-4477
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RICO
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
305-476-5160

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1010196 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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