Healthcare Provider Details

I. General information

NPI: 1639290455
Provider Name (Legal Business Name): REBELS WITH A CAUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 COMMERCE DR STE 275
CRYSTAL LAKE IL
60014-3539
US

IV. Provider business mailing address

PO BOX 249
CRYSTAL LAKE IL
60039-0249
US

V. Phone/Fax

Practice location:
  • Phone: 815-459-1502
  • Fax: 815-425-1058
Mailing address:
  • Phone: 815-459-1502
  • Fax: 815-425-1058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE ELLIOTT
Title or Position: VP
Credential:
Phone: 815-459-1502