MEDICARE: MARINE ONE, 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	347C00000X	Private Vehicle		IL

General Provider Information

NPI Number	:	1720528912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINE ONE, LLC

Provider Business Mailing Address
First Line	:	610 NEWCASTLE DR
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2783
Country	:	US
Telephone Number	:	847-226-5458
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 NEWCASTLE DR
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2783
Country	:	US
Telephone Number	:	847-226-5458
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOHN BAILEY HEMPSTEAD III
Credential	:
Telephone Number	:	847-226-5458

Provider Enumeration Date	:	03/07/2017
Last Update Date	:	03/07/2017

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Directions to “MARINE ONE, LLC ” Practice Location

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