Healthcare Provider Details

I. General information

NPI: 1982046355
Provider Name (Legal Business Name): DUBOIS-DOUGLAS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W JACKSON BLVD
CHICAGO IL
60607-2914
US

IV. Provider business mailing address

1016 W JACKSON BLVD
CHICAGO IL
60607-2914
US

V. Phone/Fax

Practice location:
  • Phone: 312-288-8640
  • Fax: 312-243-1516
Mailing address:
  • Phone: 312-288-8640
  • Fax: 312-243-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number12HM519014
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberQMXHPQ0915
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number44CSA00737
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberQXIPQ0000096439
License Number StateIL

VIII. Authorized Official

Name: MRS. FUNMI MARTINS-MENSAH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 815-295-3146