Healthcare Provider Details

I. General information

NPI: 1003864844
Provider Name (Legal Business Name): MISERICORDIA HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N RIDGE AVE
CHICAGO IL
60660-1017
US

IV. Provider business mailing address

6300 N RIDGE AVE
CHICAGO IL
60660-1017
US

V. Phone/Fax

Practice location:
  • Phone: 773-973-6300
  • Fax: 773-743-5439
Mailing address:
  • Phone: 773-973-6300
  • Fax: 773-743-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number0029876
License Number StateIL

VIII. Authorized Official

Name: MRS. DENISE TIGGES
Title or Position: ADMINISTRATOR
Credential:
Phone: 773-273-3544