MEDICARE: PURE HEARTS HOME HEALTH SERVICES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	1011202	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1011202	OTHER	IL	IDPH LICENSE #

General Provider Information

NPI Number	:	1316279037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE HEARTS HOME HEALTH SERVICES INC.

Provider Business Mailing Address
First Line	:	3839 N KEDZIE AVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60618-3413
Country	:	US
Telephone Number	:	773-588-1470
Fax Number	:	773-588-1471

Provider Business Practice Location Address
First Line	:	3839 N KEDZIE AVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60618-3413
Country	:	US
Telephone Number	:	773-588-1470
Fax Number	:	773-588-1471

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. JULIE BANASEN MEJIA
Credential	:	RN BSN
Telephone Number	:	773-588-1470

Provider Enumeration Date	:	02/04/2010
Last Update Date	:	02/04/2010

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