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General NPI Number Information
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NPI Number | 1104361633
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Entity Type | Organization
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Legal Business Name | STATE OF IL DEPT OF HUMAN SERVICES
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Dates
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Enumeration Date | 12/19/2016
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Last Update Date | 12/19/2016
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Provider Practice Location Address
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Address Line | 1617 W JEFFERSON ST
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City | JOLIET
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State | IL
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Zip | 60435-6724
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Country | US
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Telephone | 815-730-4231
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Fax |
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Provider Business Mailing Address
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Address Line | 3334 N 12,000 W ROAD
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City | BONFIELD
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State | IL
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Zip | 60913-7383
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Country | US
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Telephone | 815-426-6299
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Fax |
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Authorized Official
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Title or Position | LPN
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Name | MRS. ELIZABETH RITTENBACHER
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Credential | LPN
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Telephone | 815-426-6299
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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 | 1744428
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License Number State | IL
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