Basic Information
| Provider Information | |||||||||
| NPI: | 1477979078 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ILLINOIS LIV, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWESTERN ILLINOIS HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 TENNEY ST | ||||||||
| Address2: | |||||||||
| City: | KEWANEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614433447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096234022 | ||||||||
| FaxNumber: | 3097927296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2014 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STELLY | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0974923 | 05 | IA | MEDICAID | 421436658004 | 05 | IL | MEDICAID |