=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851487854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE HOME HEALTH CARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 12/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 HUEHL RD BLDG 20
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-480-7877
-----------------------------------------------------
Fax | 847-714-0720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 HUEHL RD BLDG 20
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-480-7877
-----------------------------------------------------
Fax | 847-714-0720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. GALINA SAFIR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-480-7877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1010131
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------