Provider Demographics
NPI:1568555316
Name:SUPPORTIVE HOME HEALTH LLC
Entity Type:Organization
Organization Name:SUPPORTIVE HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:630-830-8000
Mailing Address - Street 1:1540 BRIDLE LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-1853
Mailing Address - Country:US
Mailing Address - Phone:708-436-6949
Mailing Address - Fax:630-837-0230
Practice Address - Street 1:1540 HECHT DR
Practice Address - Street 2:SUITE H
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-1699
Practice Address - Country:US
Practice Address - Phone:630-830-8000
Practice Address - Fax:630-830-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL4243128251E00000X
IL203.000883332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========001Medicaid
IL=========002Medicaid
IL14-8153Medicare UPIN