Provider Demographics
NPI:1275907990
Name:LIFECARE@HOME
Entity Type:Organization
Organization Name:LIFECARE@HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-447-3601
Mailing Address - Street 1:5550 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-5051
Mailing Address - Country:US
Mailing Address - Phone:773-358-7438
Mailing Address - Fax:773-752-0056
Practice Address - Street 1:5550 S SHORE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-5051
Practice Address - Country:US
Practice Address - Phone:773-358-7438
Practice Address - Fax:773-752-0056
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTGOMERY PLACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-18
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3000305251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care