Provider Demographics
NPI:1235411703
Name:PRESENCE PROVISO FAMILY SERVICES INC
Entity Type:Organization
Organization Name:PRESENCE PROVISO FAMILY SERVICES INC
Other - Org Name:PROVISO FAMILY SERVICES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKLIFFE-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-914-2417
Mailing Address - Street 1:1000 REMINGTON BOULEVARD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-0000
Mailing Address - Country:US
Mailing Address - Phone:630-914-2417
Mailing Address - Fax:630-914-2499
Practice Address - Street 1:2940 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4004
Practice Address - Country:US
Practice Address - Phone:773-525-4440
Practice Address - Fax:773-525-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty