Provider Demographics
NPI:1417352105
Name:PROVIDER HEALTHCARE SERVICES, INC
Entity Type:Organization
Organization Name:PROVIDER HEALTHCARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SULAIMON
Authorized Official - Middle Name:K
Authorized Official - Last Name:OLADIPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-301-8464
Mailing Address - Street 1:555 S SCHUYLER AVE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-5146
Mailing Address - Country:US
Mailing Address - Phone:773-301-8464
Mailing Address - Fax:773-530-2643
Practice Address - Street 1:555 SOUTH SCHUYLER
Practice Address - Street 2:SUITE 275
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:773-301-8464
Practice Address - Fax:773-530-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011663251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health