Provider Demographics
NPI:1417239237
Name:LIFE HOME HEALTH CARE INC. OF SOUTHERN ILLINOIS
Entity Type:Organization
Organization Name:LIFE HOME HEALTH CARE INC. OF SOUTHERN ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRYSTAL BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENAFLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-751-4779
Mailing Address - Street 1:4503 W. DEYOUNG ST. SUITE 203C MAILBOX # 4
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-751-4779
Mailing Address - Fax:
Practice Address - Street 1:4503 W DEYOUNG ST. SUITE 203C
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-751-4779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011463251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health