Provider Demographics
NPI:1386689610
Name:PROVENA CARE AT HOME
Entity Type:Organization
Organization Name:PROVENA CARE AT HOME
Other - Org Name:PROVENA HOME MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:C
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:RN MSN
Authorized Official - Phone:815-806-2364
Mailing Address - Street 1:9223 WEST ST FRANCIS ROAD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:815-806-2300
Mailing Address - Fax:815-806-0409
Practice Address - Street 1:1100 ESSINGTON ROAD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8429
Practice Address - Country:US
Practice Address - Phone:815-773-7868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11580037332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9923629OtherBLUESHIELD
IL=========001Medicaid
IL9923629OtherBLUESHIELD