Provider Demographics
NPI:1386094068
Name:ICG HOME HEALTH
Entity type:Organization
Organization Name:ICG HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOME HEALTH RN
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANIE
Authorized Official - Middle Name:DIONNE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:708-369-1329
Mailing Address - Street 1:4508 CAMDEN CT
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4508 CAMDEN CT
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1147
Practice Address - Country:US
Practice Address - Phone:708-369-1329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041379716313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility