Healthcare Provider Details

I. General information

NPI: 1033104039
Provider Name (Legal Business Name): HOME HEALTH AGENCY ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19146 88TH AVE
MOKENA IL
60448-8135
US

IV. Provider business mailing address

510 HOSPITAL DR SUITE 100
MADISON TN
37115-5033
US

V. Phone/Fax

Practice location:
  • Phone: 708-532-4466
  • Fax: 708-532-4477
Mailing address:
  • Phone: 615-712-2250
  • Fax: 615-577-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1010196
License Number StateIL

VIII. Authorized Official

Name: JORGE RICO
Title or Position: MANAGER
Credential:
Phone: 305-476-5160