Provider Demographics
NPI:1508876541
Name:PRUDENTIAL HOME HEALTH SERVICES CORPORATION
Entity Type:Organization
Organization Name:PRUDENTIAL HOME HEALTH SERVICES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EME
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOETUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-709-0709
Mailing Address - Street 1:4440 LINCOLN HWY STE 205
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3803
Mailing Address - Country:US
Mailing Address - Phone:708-709-0709
Mailing Address - Fax:708-709-0220
Practice Address - Street 1:4440 LINCOLN HWY STE 205
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3803
Practice Address - Country:US
Practice Address - Phone:708-709-0709
Practice Address - Fax:708-709-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1525293251E00000X
251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147922Medicare Oscar/Certification