Healthcare Provider Details

I. General information

NPI: 1609420090
Provider Name (Legal Business Name): VANCLEEF PERSONAL CARE HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 E COUNTY LINE RD STE 3A-328
RIDGELAND MS
39157-1900
US

IV. Provider business mailing address

1060 E COUNTY LINE RD STE 3A-328
RIDGELAND MS
39157-1900
US

V. Phone/Fax

Practice location:
  • Phone: 773-441-1910
  • Fax: 414-386-7918
Mailing address:
  • Phone: 773-441-1910
  • Fax: 414-386-7918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: JERMAINE YOUNG
Title or Position: CEO
Credential:
Phone: 773-441-1910