Provider Demographics
NPI:1215075932
Name:EBENEZER HOME HEALTH SERVICE, LLC
Entity type:Organization
Organization Name:EBENEZER HOME HEALTH SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARILOU
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLASENOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-793-8627
Mailing Address - Street 1:16860 OAK PARK AVE STE 201C
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2787
Mailing Address - Country:US
Mailing Address - Phone:708-444-8511
Mailing Address - Fax:708-444-8514
Practice Address - Street 1:16860 OAK PARK AVE STE 201C
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2787
Practice Address - Country:US
Practice Address - Phone:708-444-8511
Practice Address - Fax:708-570-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1215075932Medicaid
IL1215075932001Medicaid
IL1010723OtherDEPT OF PUBLIC HEALTH