Healthcare Provider Details

I. General information

NPI: 1730017336
Provider Name (Legal Business Name): ANTON DWAYNE ROUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 153RD PL APT B
CALUMET CITY IL
60409-4145
US

IV. Provider business mailing address

247 153RD PL APT B
CALUMET CITY IL
60409-4145
US

V. Phone/Fax

Practice location:
  • Phone: 773-641-7451
  • Fax:
Mailing address:
  • Phone: 773-641-7451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: