Blackbag Home Physician Service LLC

Primary specialty

Health Service Clinic/CenterTaxonomy code 261QH0100X

Legal business name

BLACKBAG HOME PHYSICIAN SERVICE LLC

Practice address

437 Navajo St
Park Forest, IL 60466-2520

Phone

(815) 406-5011

Fax

(888) 311-8610

NPI assigned

Mar 9, 2013

Last updated

Dec 21, 2014By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Nichelle Hampton

Title

Chief Executive Officer

Phone

(312) 399-0285

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1362787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1419120000000",
    "number": "1770824161",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21200 S LAGRANGE RD",
            "address_2": "305",
            "city": "FRANKFORT",
            "state": "IL",
            "postal_code": "604232003",
            "telephone_number": "815-406-5011",
            "fax_number": "888-311-8610"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "437 NAVAJO ST",
            "city": "PARK FOREST",
            "state": "IL",
            "postal_code": "604662520",
            "telephone_number": "815-406-5011",
            "fax_number": "888-311-8610"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACKBAG HOME PHYSICIAN SERVICE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-03-09",
        "last_updated": "2014-12-21",
        "status": "A",
        "authorized_official_last_name": "HAMPTON",
        "authorized_official_first_name": "NICHELLE",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "312-399-0285"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Connie S Banks
• Ruth A Bartman, MA, LPC
• Lorelle Beaugard
• Jada Carol Bell, M.A., CCC-SLP
• Luisito Perez Benin, M.D.
• Bombeau Lux, LLC (Sydnie Stennis)
• Sandra Dionne Brand, LCSW
• Teri Broadnax, LDN, CNS
• Sandra Brooks
• Kenyetta N. Broughton-Floyd

• Health Service Clinic/Center in Park Forest, IL
• Providers in Park Forest, IL by specialty
• Health Service Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 21, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.