NPIMap

Organization Active NPI

Hospice of Kankakee Valley, Inc.

  • Community Based Hospice Care Agency
  • Bourbonnais, IL
National Provider Identifier
1811935240
Registry record updated Mar 24, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
2000420 Issued in IL
Legal business name
HOSPICE OF KANKAKEE VALLEY, INC.
Practice address
482 Main St NW
Bourbonnais, IL 60914-2331
Phone
(815) 939-4141
Fax
(815) 936-3375
NPI assigned
Jun 4, 2006
Last updated
Mar 24, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 24, 2014

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

Authorized official

Name
Mr. James K Turner, MBA CPA
Title
Executive Director
Phone
(815) 939-4141

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X 2000420 IL Primary
Hospice and Palliative Medicine (Family Medicine) Physician 207QH0002X 036-099237 IL

Addresses

Primary practice location

482 Main St NW
Bourbonnais, IL 60914-2331

Mailing address

482 Main St NW
Bourbonnais, IL 60914-2331
Phone (815) 939-4141

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050405000783 IL Part A Provider - Hospice 4486601184 Practice locations: Bourbonnais, IL
O20051104000312 IL Part B Supplier - Clinic/Group Practice 4486601184 Receives reassigned benefits from 4 practitioners
Practice locations: Bourbonnais, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1811935240. Details of each certification follow.

Hospice certification: CCN 141556

Legal name
HOSPICE OF KANKAKEE VALLEY, INC.
Doing business as
UPLIFTEDCARE
Certification status
Active
Provider type (POS)
Hospice
Participating since
May 26, 1993
Last certification
Nov 8, 2019
Ownership / control type
Non-Profit - Private
Organization structure
CorporationNon-profit
Incorporated
Dec 22, 1982 in IL
Enrollment address
482 Main Street NW
Bourbonnais, IL 60914

Care Compare: Hospice

Medicare Care Compare
Listed as
Uplifted CareCCN 141556 · All quality measures
Ownership
Non-Profit
Certified
May 26, 1993
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Hospice of Kankakee Valley2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Ownership & related parties

All disclosed owners & managing parties 18

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

NameRoleSinceShare
Fawn Hendershott Individual Corporate OfficerExecutive Director Jul 1, 2022 100%
W-2 Managing EmployeeExecutive Director Jul 1, 2022 100%
Abraham Thomas Individual Corporate DirectorBoard Member Nov 1, 2013 100%
Goldie (Dawn) Willbarger Individual Corporate DirectorBoard Member Jan 1, 2018 100%
Brenda Leiser Individual Corporate DirectorBoard Member Jul 1, 2016 100%
John V Jurica Individual Corporate DirectorBoard Member May 1, 2010 100%
Cheryl Mosely Individual Corporate DirectorBoard Member Jul 1, 2000 100%
Douglas Zimmerman Individual Corporate DirectorBoard Member Jul 1, 2015 100%
Robert de Oliveira Individual Corporate DirectorBoard Member Oct 5, 2021 100%
Cathy Boicken Individual Corporate DirectorBoard Member May 1, 1998
Mary Nehls Individual Corporate DirectorBoard Member May 1, 2014 100%
Mark Hodge Individual Corporate DirectorBoard Member Jul 1, 2017 100%
Dianne Schaafsma Individual Corporate DirectorBoard Member Jan 1, 1992 100%
Beverly Lemenager Individual Corporate DirectorBoard Member May 1, 2000 100%
Kalisha a Hill Individual Corporate DirectorBoard Member Jan 26, 2021 100%
Scott Piggush Individual Corporate DirectorBoard Member Jul 1, 2020 100%
Gwen Hopkins Individual Corporate DirectorBoard Member May 1, 2002 100%
Stonewall McCuiston Individual Corporate DirectorBoard Member Jul 1, 2020
Gregory Deck Individual Corporate DirectorBoard Member May 1, 1997 100%

Owners & managing parties with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 49

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

View all 49

NPI Registry JSON

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

{
    "created_epoch": "1149379200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1395619200000",
    "number": "1811935240",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "482 MAIN ST NW",
            "city": "BOURBONNAIS",
            "state": "IL",
            "postal_code": "609142331",
            "telephone_number": "815-939-4141",
            "fax_number": "815-936-3375"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "482 MAIN ST NW",
            "city": "BOURBONNAIS",
            "state": "IL",
            "postal_code": "609142331",
            "telephone_number": "815-939-4141",
            "fax_number": "815-936-3375"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HOSPICE OF KANKAKEE VALLEY, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-04",
        "last_updated": "2014-03-24",
        "status": "A",
        "authorized_official_last_name": "TURNER",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "815-939-4141",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MBA CPA"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "IL",
            "license": "2000420",
            "primary": true
        },
        {
            "code": "207QH0002X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Hospice and Palliative Medicine",
            "state": "IL",
            "license": "036-099237",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bourbonnais, IL

Sources for this page

Verify at the official NPI Registry.