Provider Demographics
NPI:1437101763
Name:PEKIN PROHEALTH INC
Entity Type:Organization
Organization Name:PEKIN PROHEALTH INC
Other - Org Name:PROCARE HOME HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-347-4663
Mailing Address - Street 1:1416 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-2103
Mailing Address - Country:US
Mailing Address - Phone:309-347-4663
Mailing Address - Fax:309-347-5127
Practice Address - Street 1:1416 N 8TH ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-2103
Practice Address - Country:US
Practice Address - Phone:309-347-4663
Practice Address - Fax:309-347-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000261332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid