Provider Demographics
NPI:1386867935
Name:LIVING WATERS HOME HEALTH CARE INC
Entity Type:Organization
Organization Name:LIVING WATERS HOME HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BERMUDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:773-202-8043
Mailing Address - Street 1:4001 W DEVON AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4523
Mailing Address - Country:US
Mailing Address - Phone:773-202-8043
Mailing Address - Fax:773-202-8048
Practice Address - Street 1:4001 W DEVON AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4523
Practice Address - Country:US
Practice Address - Phone:773-202-8043
Practice Address - Fax:773-202-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010420251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147857Medicare ID - Type UnspecifiedHOME HEALTH PROVIDER NO.