=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083343198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CHOICE HOME CARE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2022
-----------------------------------------------------
Last Update Date | 06/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10858 BRAEMAR PKWY
-----------------------------------------------------
City | HUNTLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60142-9014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-509-5935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12172 S RTE 47 #141
-----------------------------------------------------
City | HUNTLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-509-5935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMELISSA LAGROSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 224-509-5535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------