Provider Demographics
NPI:1538460670
Name:QUALITY LIFE PROVIDERS LLC
Entity Type:Organization
Organization Name:QUALITY LIFE PROVIDERS LLC
Other - Org Name:QUALITY LIFE PROVIDERS, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA, MBA
Authorized Official - Phone:847-980-6325
Mailing Address - Street 1:4166 BLANCHAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1802
Mailing Address - Country:US
Mailing Address - Phone:847-980-6325
Mailing Address - Fax:708-387-2348
Practice Address - Street 1:4166 BLANCHAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1802
Practice Address - Country:US
Practice Address - Phone:847-980-6325
Practice Address - Fax:708-387-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002055363LG0600X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP52930Medicaid
IL201008Medicare PIN
ILP52930Medicaid