MEDICARE: HOME BOUND HEALTHCARE HOSPICE, 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	251G00000X	Community Based Hospice Care Agency	PENDING	IL
2	251G00000X	Community Based Hospice Care Agency	2002863	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	072-2002863	OTHER	IL	ILLINOIS DEPARTMENT OF PUBLIC HEALTH STATE LICENSE
2	14D2012259	OTHER	IL	CLIA ID NUMBER

General Provider Information

NPI Number	:	1710298187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME BOUND HEALTHCARE HOSPICE, LLC

Provider Business Mailing Address
First Line	:	14216 MCCARTHY RD
Second Line	:
City	:	LEMONT
State	:	IL
Zip	:	60439-9393
Country	:	US
Telephone Number	:	630-914-5140
Fax Number	:	630-914-5148

Provider Business Practice Location Address
First Line	:	14216 MCCARTHY RD
Second Line	:
City	:	LEMONT
State	:	IL
Zip	:	60439-9393
Country	:	US
Telephone Number	:	630-914-5140
Fax Number	:	630-914-5148

Authorized Official
Title or Position	:	PRESIDENT/SECRETARY/TREASURER
Name	:	MRS. JULIETA R MITRA
Credential	:
Telephone Number	:	630-914-5140

Provider Enumeration Date	:	06/30/2010
Last Update Date	:	03/09/2017

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