=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407093347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURE CARE HOME SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2009
-----------------------------------------------------
Last Update Date | 01/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1155 N MAIN ST SUITE C & D
-----------------------------------------------------
City | GLENDALE HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60139-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-295-9058
-----------------------------------------------------
Fax | 630-295-9059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1155 N MAIN ST SUITE C & D
-----------------------------------------------------
City | GLENDALE HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60139-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-295-9058
-----------------------------------------------------
Fax | 630-295-9059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. MYLENE MASICLAT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-295-9058
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 66258807
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------