Organization
PROVENA CARE AT HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHEAL GORDON (CHIEF FINANCIAL OFFICER)
(708) 478-7911
Entity
Organization
Contact information
Practice address
1100 ESSINGTON ROAD, JOLIET, IL 60435-8429
(815) 773-7868
Mailing address
9223 WEST ST FRANCIS ROAD, FRANKFORT, IL 60423
(815) 806-2300
(815) 806-0409
Taxonomy
Speciality
Code
Description
License number
State
251J00000X
Nursing Care Agency
Primary
1731163
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
09923567
BLUE SHIELD
IL
Enumeration date
06/19/2006
Last updated
05/08/2013
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