Healthcare Provider Details

I. General information

NPI: 1912918699
Provider Name (Legal Business Name): HOME MD LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3426 W ARMITAGE AVE
CHICAGO IL
60647-3720
US

IV. Provider business mailing address

3426 W ARMITAGE AVE
CHICAGO IL
60647-3720
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-8770
  • Fax: 847-307-8314
Mailing address:
  • Phone: 773-772-8770
  • Fax: 847-307-8314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JESUS RENE DADIVAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-772-8770