Provider Demographics
NPI:1689670382
Name:DYNAMIC HOMECARE INC
Entity Type:Organization
Organization Name:DYNAMIC HOMECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEATRICE
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:GREATHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:217-345-4614
Mailing Address - Street 1:546 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2442
Mailing Address - Country:US
Mailing Address - Phone:217-345-4614
Mailing Address - Fax:217-348-0057
Practice Address - Street 1:546 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2442
Practice Address - Country:US
Practice Address - Phone:217-345-4614
Practice Address - Fax:217-348-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1642234251E00000X
IL1655311251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251E00000XAgenciesHome Health
Not Answered251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========001Medicaid
IL=========002Medicaid
IL147617Medicare ID - Type UnspecifiedHOME HEALTH AGENCY