MEDICARE: DIVINE LIGHT HOMECARE LLC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1376149468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE LIGHT HOMECARE LLC

Provider Business Mailing Address
First Line	:	71 NICHOLAS DR W
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-6221
Country	:	US
Telephone Number	:	312-792-6477
Fax Number	:	847-789-9728

Provider Business Practice Location Address
First Line	:	875 N MICHIGAN AVE # 3178
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-1803
Country	:	US
Telephone Number	:	224-488-0600
Fax Number	:	847-789-9728

Authorized Official
Title or Position	:	PRESIDENT/AGENCY MANAGER
Name	:	MRS. IMOLEAYO MARY OLUYEDE
Credential	:
Telephone Number	:	312-792-6477

Provider Enumeration Date	:	12/05/2020
Last Update Date	:	12/05/2020

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