NPIMap

Organization Active NPI

Rest Haven Illiana Christian Convalescent Home

  • Community Based Hospice Care Agency
  • Homer Glen, IL
National Provider Identifier
1407855562
Registry record updated May 26, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
2002251 Issued in IL
Legal business name
REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Practice address
14301 Independence Way
Homer Glen, IL 60491-7210
Phone
(708) 331-0400
Fax
(708) 877-4818
NPI assigned
Jul 20, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 26, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Johanna Zandstra
Title
VP of Operations
Phone
(708) 342-8100

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Hospice and Palliative Medicine (Internal Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RH0002X
Community Based Hospice Care Agency 251G00000X 2002251 IL Primary

Addresses

Primary practice location

14301 Independence Way
Homer Glen, IL 60491-7210

Mailing address

14301 Independence Way
Homer Glen, IL 60491-7210
Phone (800) 509-2800

Other identifiers 1

IdentifierTypeStateIssuer
2002251OtherILHOSPICE LICENSE NUMBER

Other names 1

  • Providence Hospice Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100324000540 IL Part A Provider - Hospice 1052221470 Practice locations: Homer Glen, IL
O20140214000742 IL Part B Supplier - Clinic/Group Practice 1052221470 Receives reassigned benefits from 3 practitioners
Practice locations: Homer Glen, IL

Hospice certification: CCN 141609

Legal name
REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Doing business as
PROVIDENCE HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Feb 10, 2003
Last certification
Aug 27, 2020
Ownership / control type
Non-Profit - Church
Organization structure
CorporationNon-profit
Incorporated
Apr 6, 1956 in IL
Enrollment address
14301 Independence Way
Homer Glen, IL 60491-7210

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospice

Medicare Care Compare
Listed as
Providence HospiceCCN 141609
Ownership
Non-Profit
Certified
Feb 10, 2003
Medicare certification status
ActiveFrom the Provider of Services file

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D0987662Providence Hospice14301 Independence, Homer Glen, IL 60491Certificate of waiverJun 10, 2027

National Provider Directory

National Provider Directory
Tax ID family
Rest Haven Illiana Christian Convalescent Home4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Member organizations 8

Organizations listed as members of this organization in the National Provider Directory.

Locations

14301 Independence Way
Homer Glen, IL 60491
Phone (708) 331-0400

Ownership & related parties

All disclosed owners & managing parties 20

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kenneth Alan Hoving Individual Corporate DirectorAsst. Secretary/Treasurer Apr 1, 2022
Rest Haven Illiana Christian Convalescent Home Organization, Tinley Park, IL Non-profit, Chain home office 5% Or Greater Direct Ownership Interest Feb 10, 2003 100%
Johanna Zandstra Individual W-2 Managing EmployeeCompliance Officer Apr 24, 2000
Darren Van Essen Individual Corporate Director Apr 1, 2022
Sandhya Nagubadi Individual Contracted Managing EmployeeMD; Feb 1, 2019
Paul Buikema Individual Corporate Director Apr 1, 2022
Theodore Earle Feenstra Individual Corporate Director Apr 1, 2024
Edward Damstra Individual Corporate Director Apr 1, 2022
Barry Vandergenugten Individual W-2 Managing Employee May 31, 2001
David Voss Individual Corporate Director Apr 1, 2022
Eric M Woo Individual Corporate Director Apr 1, 2024
Karen Huizenga Individual Corporate Director Apr 1, 2022
Tim Breems Individual Corporate Director Apr 1, 2024
Kyle Yonker Individual Corporate Director Apr 1, 2024
Gary W Leo Individual Corporate Director Apr 1, 2024
Arnold Koldenhoven Individual Corporate Director Apr 1, 2024
Rob Petroelje Individual Corporate Director Apr 1, 2024
Patricia L Jabaay Individual Corporate Director Apr 1, 2022
Dave Degraff Individual Corporate Director Apr 1, 2024
Amy Mosoriak Individual W-2 Managing EmployeeHospice Administrator Apr 1, 2022

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Park Place Christian CommunityElmhurst, IL, CCN 146155 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Adp of the SNF		 May 5, 2004
Aug 23, 2012
Providence Life ServicesHomer Glen, IL, CCN 146178 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Adp of the SNF		 Jan 26, 2015
Jan 26, 2015
Rest Haven Illiana Christian Convalescent HomeHomer Glen, IL, CCN 147559 Home health agency 5% Or Greater Direct Ownership Interest (100%) Mar 30, 1994
Providence Hospice, Inc.Saint John, IN, CCN 151624 Hospice 5% Or Greater Direct Ownership Interest (100%) Jun 15, 2016

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 10

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1779753600000",
    "number": "1407855562",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14301 INDEPENDENCE WAY",
            "city": "HOMER GLEN",
            "state": "IL",
            "postal_code": "604917210",
            "telephone_number": "800-509-2800",
            "fax_number": "708-877-4818"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14301 INDEPENDENCE WAY",
            "city": "HOMER GLEN",
            "state": "IL",
            "postal_code": "604917210",
            "telephone_number": "708-331-0400",
            "fax_number": "708-877-4818"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-20",
        "last_updated": "2026-05-26",
        "certification_date": "2026-05-26",
        "status": "A",
        "authorized_official_last_name": "ZANDSTRA",
        "authorized_official_first_name": "JOHANNA",
        "authorized_official_title_or_position": "VP OF OPERATIONS",
        "authorized_official_telephone_number": "708-342-8100"
    },
    "taxonomies": [
        {
            "code": "207RH0002X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Hospice and Palliative Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "IL",
            "license": "2002251",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HOSPICE LICENSE NUMBER",
            "identifier": "2002251",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Hospice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Hospice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Homer Glen, IL

Sources for this page

Verify at the official NPI Registry.