1063518850 NPI number — CARBONDALE REHABILITATION AND NURSING CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063518850 NPI number — CARBONDALE REHABILITATION AND NURSING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARBONDALE REHABILITATION AND NURSING CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OAK GROVE REHABILITATION AND SKILLED CARE
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063518850
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8707 SKOKIE BLVD
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60077-2269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-236-0000
Provider Business Mailing Address Fax Number:
708-236-0001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 N TOWER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-549-3355
Provider Business Practice Location Address Fax Number:
618-549-0484
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLISKO
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
C.F.O
Authorized Official Telephone Number:
708-236-0000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0041418 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6009203 . This is a "FACILITY ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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