MEDICARE: PASSIONATE PRIVATE DUTY, 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	251J00000X	Nursing Care Agency	4000558	IL

General Provider Information

NPI Number	:	1619480191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASSIONATE PRIVATE DUTY, LLC

Provider Business Mailing Address
First Line	:	2401 W US HIGHWAY 20 STE 202
Second Line	:
City	:	PINGREE GROVE
State	:	IL
Zip	:	60140-8819
Country	:	US
Telephone Number	:	847-975-3950
Fax Number	:	847-972-0600

Provider Business Practice Location Address
First Line	:	2401 W US HIGHWAY 20
Second Line	:
City	:	PINGREE GROVE
State	:	IL
Zip	:	60140-8818
Country	:	US
Telephone Number	:	847-975-3950
Fax Number	:	847-792-0600

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. CAROLE A JENSEN
Credential	:
Telephone Number	:	847-975-3950

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	11/07/2017

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Directions to “PASSIONATE PRIVATE DUTY, LLC ” Practice Location

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