Healthcare Provider Details

I. General information

NPI: 1609152867
Provider Name (Legal Business Name): FICC HOME HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5648 W. LAWRENCE AVE.
CHICAGO IL
60630-3220
US

IV. Provider business mailing address

5648 W. LAWRENCE AVE.
CHICAGO IL
60630-3220
US

V. Phone/Fax

Practice location:
  • Phone: 773-283-2835
  • Fax: 773-283-2955
Mailing address:
  • Phone: 773-283-2835
  • Fax: 773-283-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1011364
License Number StateIL

VIII. Authorized Official

Name: MR. BRYAN POTTOW
Title or Position: PRESIDENT
Credential:
Phone: 773-283-2835