Healthcare Provider Details

I. General information

NPI: 1073323788
Provider Name (Legal Business Name): MR. DEMETRIO HAMOY BUSTALINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4507 LINDEN LN
ROLLING MEADOWS IL
60008-3427
US

IV. Provider business mailing address

4507 LINDEN LN
ROLLING MEADOWS IL
60008-3427
US

V. Phone/Fax

Practice location:
  • Phone: 224-410-7520
  • Fax:
Mailing address:
  • Phone: 224-410-7520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number14242295
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number14242295
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number14242295
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: