=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063620136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALITY CARE HOMEHEALTH INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2007
-----------------------------------------------------
Last Update Date | 03/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4214 W 21ST ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-2754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-277-8663
-----------------------------------------------------
Fax | 773-277-1767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4214 W 21ST ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-2754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-277-8663
-----------------------------------------------------
Fax | 773-277-1767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. SANDRA STAFFORD
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 773-277-8663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | IL1010215
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------