Basic Information
| Provider Information | |||||||||
| NPI: | 1477505139 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAUKEGAN HOSPICE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STAR HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9510 ORMSBY STATION RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402234081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028911187 | ||||||||
| FaxNumber: | 5028918067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1790 NATIONS DR | ||||||||
| Address2: | STE 205 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600319164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476729225 | ||||||||
| FaxNumber: | 8476729593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | LYLES | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5028911044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
No ID Information.