Provider Demographics
NPI:1073867784
Name:WELLPOINT HOME HEALTH,INC.
Entity Type:Organization
Organization Name:WELLPOINT HOME HEALTH,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:773-732-8790
Mailing Address - Street 1:10912 S WESTERN AVE
Mailing Address - Street 2:SUITE 4 N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3205
Mailing Address - Country:US
Mailing Address - Phone:773-253-9190
Mailing Address - Fax:773-253-9961
Practice Address - Street 1:10912 S WESTERN AVE
Practice Address - Street 2:SUITE 4 N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3205
Practice Address - Country:US
Practice Address - Phone:773-253-9190
Practice Address - Fax:773-253-9961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011534251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health