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General NPI Number Information
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NPI Number | 1033404363
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Entity Type | Organization
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Legal Business Name | INTERACTIVE HEALTHCARE OF CENTRAL ILLINOIS
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Dates
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Enumeration Date | 06/15/2011
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Last Update Date | 06/15/2011
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Provider Practice Location Address
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Address Line | 1701 S 1ST AVE SUITE 503
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City | MAYWOOD
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State | IL
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Zip | 60153-2442
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Country | US
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Telephone | 708-344-7930
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Fax | 708-344-7932
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Provider Business Mailing Address
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Address Line | 1701 S 1ST AVE SUITE 503
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City | MAYWOOD
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State | IL
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Zip | 60153-2442
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Country | US
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Telephone | 708-344-7930
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Fax | 708-344-7932
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PAUL GOSSMAN
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Credential |
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Telephone | 708-344-7930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 1011482
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License Number State | IL
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