Provider Demographics
NPI:1013269737
Name:ILLINOIS EXPRESS HOME CARE
Entity Type:Organization
Organization Name:ILLINOIS EXPRESS HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-727-0453
Mailing Address - Street 1:3641 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-5437
Mailing Address - Country:US
Mailing Address - Phone:314-727-0453
Mailing Address - Fax:
Practice Address - Street 1:4601 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-1359
Practice Address - Country:US
Practice Address - Phone:314-727-0453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXPRESS HOME CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL4000369253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care