Healthcare Provider Details

I. General information

NPI: 1962497735
Provider Name (Legal Business Name): NORTHERN ILLINOIS HOME MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 N GALENA AVE
DIXON IL
61021-1060
US

IV. Provider business mailing address

1309 N GALENA AVE
DIXON IL
61021-1060
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-5857
  • Fax: 815-285-5858
Mailing address:
  • Phone: 815-285-5857
  • Fax: 815-285-5858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. ROBERT LESAGE
Title or Position: PRESIDENT
Credential:
Phone: 815-284-8200