Provider Demographics
NPI:1659320869
Name:PRESENCE HOME CARE
Entity Type:Organization
Organization Name:PRESENCE HOME CARE
Other - Org Name:PRESENCE HOME CARE - URBANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-7911
Mailing Address - Street 1:9223 WEST ST FRANCIS ROAD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-8334
Mailing Address - Country:US
Mailing Address - Phone:815-806-2300
Mailing Address - Fax:815-806-0409
Practice Address - Street 1:1501 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1006
Practice Address - Country:US
Practice Address - Phone:217-355-4120
Practice Address - Fax:217-355-4121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVENA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-08
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010264251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4604853581004Medicaid
IL50162OtherBC BS
147132Medicare Oscar/Certification