=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508173535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AC PERFORMANCE PRO SYS HEWITT HOME CARE-AC PERF PRO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2010
-----------------------------------------------------
Last Update Date | 10/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5135 S BLACKSTONE AVE APT 200
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-6309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-675-6381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5135 S BLACKSTONE APT 200
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-675-6381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSING MANAGER
-----------------------------------------------------
Name | MRS. CECILY MICHELLE HEWITT
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 773-675-6381
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 330483055
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------