Healthcare Provider Details

I. General information

NPI: 1275938912
Provider Name (Legal Business Name): PROVIDENCE HOMECARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6965 N WESTERN AVE
CHICAGO IL
60645-4710
US

IV. Provider business mailing address

6965 N WESTERN AVE
CHICAGO IL
60645-4710
US

V. Phone/Fax

Practice location:
  • Phone: 773-274-3627
  • Fax:
Mailing address:
  • Phone: 773-274-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: WILSON ATIABET
Title or Position: OWNER
Credential:
Phone: 773-274-3627