=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386884005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROLIFE HOME HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2009
-----------------------------------------------------
Last Update Date | 03/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4836 MAIN ST SUITE 105
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-2594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-674-1110
-----------------------------------------------------
Fax | 847-674-1101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4836 MAIN ST SUITE 105
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-2594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-674-1110
-----------------------------------------------------
Fax | 847-674-1101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSING SUPERVISOR
-----------------------------------------------------
Name | MISS SARAH JANE TRIUMFANTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-807-1960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1010909
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------