Provider Demographics
NPI:1912171752
Name:LADYBERN MEDICAR COMPANY
Entity type:Organization
Organization Name:LADYBERN MEDICAR COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-239-0816
Mailing Address - Street 1:9622A S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1005
Mailing Address - Country:US
Mailing Address - Phone:773-239-0816
Mailing Address - Fax:
Practice Address - Street 1:9622A S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1005
Practice Address - Country:US
Practice Address - Phone:773-239-0816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH425-0604-6940343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6062801Medicaid