=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467909598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKOKIE HOME AND NURSING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2016
-----------------------------------------------------
Last Update Date | 09/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4207 BIRCHWOOD AVE
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076-3859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-208-2935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4207 BIRCHWOOD AVE
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MARIE ESTHER FENELON
-----------------------------------------------------
Credential | MHEP
-----------------------------------------------------
Telephone | 847208293547
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 3001334
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | 4000511
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------