1063518850 NPI number — CARBONDALE REHABILITATION AND NURSING CENTER, LLC

Table of content: (NPI 1063518850)

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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