Basic Information
| Provider Information | |||||||||
| NPI: | 1518980614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GALESBURG HOME CARE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIDWEST REGIONAL HOME CARE/OPTION CARE MIDWEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 427 E FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614010505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093439031 | ||||||||
| FaxNumber: | 3093438057 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 E FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614010505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093439031 | ||||||||
| FaxNumber: | 3093438057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RINEHART | ||||||||
| AuthorizedOfficialFirstName: | TEDDIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3093439031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | X | Suppliers | Durable Medical Equipment & Medical Supplies | 251F00000X | IL | X | Agencies | Home Infusion |
ID Information
| ID | Type | State | Issuer | Description | 0749119 | 05 | IA | MEDICAID |