Healthcare Provider Details

I. General information

NPI: 1770761082
Provider Name (Legal Business Name): POLO HCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 E BUFFALO ST
POLO IL
61064-1701
US

IV. Provider business mailing address

703 E BUFFALO ST
POLO IL
61064-1701
US

V. Phone/Fax

Practice location:
  • Phone: 815-946-2203
  • Fax: 815-946-2895
Mailing address:
  • Phone: 815-946-2203
  • Fax: 816-276-0150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0028852
License Number StateIL

VIII. Authorized Official

Name: STEPHANIE REDBURN
Title or Position: REVENUE CYCLE COMPLIANCE AUDITOR
Credential:
Phone: 816-444-0900