Provider Demographics
NPI:1619436904
Name:HOME CLINIC LLC
Entity Type:Organization
Organization Name:HOME CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:T
Authorized Official - Last Name:STACHURA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CLT
Authorized Official - Phone:708-227-8403
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60918-0024
Mailing Address - Country:US
Mailing Address - Phone:708-227-8403
Mailing Address - Fax:
Practice Address - Street 1:109 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:IL
Practice Address - Zip Code:60918-7044
Practice Address - Country:US
Practice Address - Phone:708-227-8403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy