=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457360059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURE CARE HOME HEALTH,CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 11/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1155 N MAIN ST SUITE C & D
-----------------------------------------------------
City | GLENDALE HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60139-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 186-676-5119
-----------------------------------------------------
Fax | 847-805-9832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1155 N MAIN ST SUITE C & D
-----------------------------------------------------
City | GLENDALE HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60139-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 186-676-5119
-----------------------------------------------------
Fax | 847-805-9832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/DON
-----------------------------------------------------
Name | MRS. ZOSIMA VICTUELLES
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 18667651197
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1010375
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------