Provider Demographics
NPI:1033104039
Name:HOME HEALTH AGENCY ILLINOIS, LLC
Entity Type:Organization
Organization Name:HOME HEALTH AGENCY ILLINOIS, LLC
Other - Org Name:OMNI HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-476-5160
Mailing Address - Street 1:510 HOSPITAL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-5033
Mailing Address - Country:US
Mailing Address - Phone:615-712-2250
Mailing Address - Fax:615-577-0081
Practice Address - Street 1:19146 88TH AVE
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8135
Practice Address - Country:US
Practice Address - Phone:708-532-4466
Practice Address - Fax:708-532-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010196251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL147732Medicare Oscar/Certification