1568555316 NPI number — SUPPORTIVE HOME HEALTH LLC

Table of content: (NPI 1568555316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568555316 NPI number — SUPPORTIVE HOME HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPPORTIVE HOME HEALTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568555316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1540 BRIDLE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTLETT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60103-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-436-6949
Provider Business Mailing Address Fax Number:
630-837-0230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1540 HECHT DR
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
BARTLETT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60103-1699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-830-8000
Provider Business Practice Location Address Fax Number:
630-830-8004
Provider Enumeration Date:
10/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOLAN
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
DWIGHT
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
630-830-8000

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  4243128 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: 203.000883 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)