Provider Demographics
NPI:1811935240
Name:HOSPICE OF KANKAKEE VALLEY, INC.
Entity type:Organization
Organization Name:HOSPICE OF KANKAKEE VALLEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA CPA
Authorized Official - Phone:815-939-4141
Mailing Address - Street 1:482 MAIN ST NW
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2331
Mailing Address - Country:US
Mailing Address - Phone:815-939-4141
Mailing Address - Fax:815-936-3375
Practice Address - Street 1:482 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2331
Practice Address - Country:US
Practice Address - Phone:815-939-4141
Practice Address - Fax:815-936-3375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-099237207QH0002X
IL2000420251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community BasedGroup - Single Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL212501Medicare Oscar/Certification
IL141556Medicare Oscar/Certification
K22142Medicare UPIN