Healthcare Provider Details

I. General information

NPI: 1275907990
Provider Name (Legal Business Name): LIFECARE@HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 S SHORE DR
CHICAGO IL
60637-5051
US

IV. Provider business mailing address

5550 S SHORE DR
CHICAGO IL
60637-5051
US

V. Phone/Fax

Practice location:
  • Phone: 773-358-7438
  • Fax: 773-752-0056
Mailing address:
  • Phone: 773-358-7438
  • Fax: 773-752-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number3000305
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number3000305
License Number StateIL

VIII. Authorized Official

Name: MR. BOBBY POPE
Title or Position: ADMINISTRATOR
Credential:
Phone: 774-447-3601