Healthcare Provider Details

I. General information

NPI: 1376166637
Provider Name (Legal Business Name): SPRINGFIELD ILLINOIS HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2731 S MACARTHUR BLVD STE 201
SPRINGFIELD IL
62704-5081
US

IV. Provider business mailing address

2731 S MACARTHUR BLVD STE 201
SPRINGFIELD IL
62704-5081
US

V. Phone/Fax

Practice location:
  • Phone: 217-299-2928
  • Fax: 217-568-6309
Mailing address:
  • Phone: 217-299-2928
  • Fax: 217-568-6309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: MR. ROD A LANE
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential: MBA
Phone: 217-299-2928