Provider Demographics
NPI:1942307145
Name:DIVINE PROVIDENCE HOME HEALTH AGENCY, INC.
Entity type:Organization
Organization Name:DIVINE PROVIDENCE HOME HEALTH AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ARNOLD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:DONATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-433-3320
Mailing Address - Street 1:3550 W PETERSON AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3270
Mailing Address - Country:US
Mailing Address - Phone:773-433-3320
Mailing Address - Fax:773-433-3329
Practice Address - Street 1:3550 W PETERSON AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3270
Practice Address - Country:US
Practice Address - Phone:773-433-3320
Practice Address - Fax:773-433-3329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010341251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1010341OtherHOME HEALTH LICENSE
IL1010341OtherHOME HEALTH LICENSE
IL=========001Medicaid