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General NPI Number Information
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NPI Number | 1982886974
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Entity Type | Organization
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Legal Business Name | GERIACARE HOME HEALTHCARE INC
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Dates
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Enumeration Date | 11/30/2007
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Last Update Date | 02/15/2013
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Provider Practice Location Address
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Address Line | 450 E 22ND ST SUITE 172
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City | LOMBARD
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State | IL
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Zip | 60148-6113
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Country | US
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Telephone | 630-620-9305
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Fax | 630-216-1150
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Provider Business Mailing Address
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Address Line | 450 E 22ND ST SUITE 172
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City | LOMBARD
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State | IL
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Zip | 60148-6113
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Country | US
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Telephone | 630-620-9305
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Fax | 630-216-1150
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Authorized Official
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Title or Position | ADMINISTRATOR/AGENCY SUPERVISOR
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Name | MR. ROY BONGON SIAPNO
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Credential | BSN RN
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Telephone | 630-620-9305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 1010750
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License Number State | IL
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