Healthcare Provider Details

I. General information

NPI: 1417622705
Provider Name (Legal Business Name): INNOVATIVE SENIOR CARE HOME HEALTH OF CHICAGO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 ONTARIO ST
OAK PARK IL
60302-1939
US

IV. Provider business mailing address

PO BOX 51266
LAFAYETTE LA
70505-1266
US

V. Phone/Fax

Practice location:
  • Phone: 708-934-7149
  • Fax: 708-934-7148
Mailing address:
  • Phone: 337-233-1307
  • Fax: 337-443-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA L. PROFFITT
Title or Position: PRESIDENT
Credential:
Phone: 337-233-1307