Healthcare Provider Details

I. General information

NPI: 1093976839
Provider Name (Legal Business Name): HOME IMAGES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 207TH PL
LYNWOOD IL
60411-1538
US

IV. Provider business mailing address

PO BOX 1013
MATTESON IL
60443-4013
US

V. Phone/Fax

Practice location:
  • Phone: 630-788-4527
  • Fax:
Mailing address:
  • Phone: 630-788-4527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberPENDING
License Number StateIL

VIII. Authorized Official

Name: M C HEARON
Title or Position: PRESIDENT
Credential:
Phone: 630-788-4527