1205885407 NPI number — PROVENA HOME HEALTH INC

Table of content: (NPI 1205885407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205885407 NPI number — PROVENA HOME HEALTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVENA HOME HEALTH INC
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:
Provider Other Organization Name Type Code:
6
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:
1205885407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9223 WEST ST FRANCIS ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKFORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60423-8334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-806-2300
Provider Business Mailing Address Fax Number:
815-806-0409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 NORTH AIRLITE
Provider Second Line Business Practice Location Address:
MOB1 SUITE 120
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60123-4912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-931-5553
Provider Business Practice Location Address Fax Number:
847-622-2055
Provider Enumeration Date:
05/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLEASON
Authorized Official First Name:
MARGARET
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
815-806-2364

Provider Taxonomy Codes

  • Taxonomy code: 251F00000X , with the licence number:  1010260 , 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)

  • Identifier: 04523557 . This is a "BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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