Provider Demographics
NPI:1780006619
Name:VILLASENOR IN-HOME PATIENT CARE LLC
Entity Type:Organization
Organization Name:VILLASENOR IN-HOME PATIENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLASENOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:708-788-2801
Mailing Address - Street 1:1639 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1782
Mailing Address - Country:US
Mailing Address - Phone:708-788-2801
Mailing Address - Fax:847-787-5252
Practice Address - Street 1:1639 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1782
Practice Address - Country:US
Practice Address - Phone:708-788-2801
Practice Address - Fax:847-787-5252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL48052Medicare UPIN