Provider Demographics
NPI:1710298187
Name:HOME BOUND HEALTHCARE HOSPICE, LLC
Entity Type:Organization
Organization Name:HOME BOUND HEALTHCARE HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY/TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIETA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MITRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-914-5140
Mailing Address - Street 1:14216 MCCARTHY RD
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-9393
Mailing Address - Country:US
Mailing Address - Phone:630-914-5140
Mailing Address - Fax:630-914-5148
Practice Address - Street 1:14216 MCCARTHY RD
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-9393
Practice Address - Country:US
Practice Address - Phone:630-914-5140
Practice Address - Fax:630-914-5148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPENDING251G00000X
IL2002863251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL072-2002863OtherILLINOIS DEPARTMENT OF PUBLIC HEALTH STATE LICENSE
IL14D2012259OtherCLIA ID NUMBER
IL14D2012259OtherCLIA ID NUMBER