Provider Demographics
NPI:1801845896
Name:PROFESSIONAL HOME CARE ADVANTAGE, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL HOME CARE ADVANTAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BOLARINWA
Authorized Official - Middle Name:P
Authorized Official - Last Name:ADEOYE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BA, BSN, RN, MSN
Authorized Official - Phone:708-891-2013
Mailing Address - Street 1:2521 RIDGE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2792
Mailing Address - Country:US
Mailing Address - Phone:708-858-2939
Mailing Address - Fax:708-889-6317
Practice Address - Street 1:2521 RIDGE RD STE 1
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2792
Practice Address - Country:US
Practice Address - Phone:708-858-2939
Practice Address - Fax:708-889-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1686069251E00000X
251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5627273Medicaid
IL147660Medicaid