Provider Demographics
NPI:1649215831
Name:PROVENA CARE AT HOME
Entity type:Organization
Organization Name:PROVENA CARE AT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-7911
Mailing Address - Street 1:9223 WEST ST FRANCIS ROAD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:815-806-2300
Mailing Address - Fax:815-806-0409
Practice Address - Street 1:1100 ESSINGTON ROAD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8429
Practice Address - Country:US
Practice Address - Phone:815-773-7868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1731163251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09923567OtherBLUE SHIELD