Provider Demographics
NPI:1477502672
Name:PROVENA HOME HEALTH INC
Entity Type:Organization
Organization Name:PROVENA HOME HEALTH INC
Other - Org Name:PROVENA HOME HEALTH INC WAUKEGAN
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:60423-8334
Mailing Address - Country:US
Mailing Address - Phone:815-806-2300
Mailing Address - Fax:815-806-0409
Practice Address - Street 1:222 SOUTH GREENLEAF AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5705
Practice Address - Country:US
Practice Address - Phone:847-360-7660
Practice Address - Fax:847-360-8411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVENA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-08
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010261251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50163OtherBC BS
IL50163OtherBC BS
IL=========001Medicaid