Provider Demographics
NPI:1790736478
Name:OMNICARE HOME HEALTH INC.
Entity Type:Organization
Organization Name:OMNICARE HOME HEALTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIBERTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANONUEVO
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:630-972-0668
Mailing Address - Street 1:550 E. BOUGHTON RD.
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2192
Mailing Address - Country:US
Mailing Address - Phone:630-972-0668
Mailing Address - Fax:630-972-0669
Practice Address - Street 1:550 E. BOUGHTON RD.
Practice Address - Street 2:SUITE 130
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2192
Practice Address - Country:US
Practice Address - Phone:630-972-0668
Practice Address - Fax:630-972-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010554251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6044001Medicaid
IL=========001Medicaid
IL=========6044001Medicaid