1467754994 NPI number — SOLID SOURCE HEALTHCARE RESOURCES LLC HOME SERVICES

Table of content: (NPI 1467754994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467754994 NPI number — SOLID SOURCE HEALTHCARE RESOURCES LLC HOME SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOLID SOURCE HEALTHCARE RESOURCES LLC HOME SERVICES
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:
1467754994
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 OTTAWA AVE
Provider Second Line Business Mailing Address:
UNIT 2
Provider Business Mailing Address City Name:
OTTAWA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61350-3321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
779-279-4888
Provider Business Mailing Address Fax Number:
888-577-1171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 W SUPERIOR ST
Provider Second Line Business Practice Location Address:
UNIT 1
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61350-2093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-324-9396
Provider Business Practice Location Address Fax Number:
888-577-1171
Provider Enumeration Date:
12/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN-GREENFIELD
Authorized Official First Name:
TOSHETA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
815-324-9396

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  4000322 , 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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