Provider Demographics
NPI:1477505139
Name:WAUKEGAN HOSPICE, LLC
Entity Type:Organization
Organization Name:WAUKEGAN HOSPICE, LLC
Other - Org Name:STAR HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:LYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-891-1044
Mailing Address - Street 1:9510 ORMSBY STATION RD
Mailing Address - Street 2:STE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4081
Mailing Address - Country:US
Mailing Address - Phone:502-891-1187
Mailing Address - Fax:502-891-8067
Practice Address - Street 1:1790 NATIONS DR
Practice Address - Street 2:STE 205
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-9164
Practice Address - Country:US
Practice Address - Phone:847-672-9225
Practice Address - Fax:847-672-9593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141543Medicare Oscar/Certification