Healthcare Provider Details

I. General information

NPI: 1730940479
Provider Name (Legal Business Name): JOHN BAGENDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18W140 BUTTERFIELD RD FL 15
OAKBROOK TERRACE IL
60181-4843
US

IV. Provider business mailing address

18W140 BUTTERFIELD RD FL 15
OAKBROOK TERRACE IL
60181-4843
US

V. Phone/Fax

Practice location:
  • Phone: 630-613-7788
  • Fax: 630-613-7787
Mailing address:
  • Phone: 630-613-7788
  • Fax: 630-613-7787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: