1528624681 NPI number — PIERRE SD SKILLED NURSING FACILITY 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 1528624681 NPI number — PIERRE SD SKILLED NURSING FACILITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIERRE SD SKILLED NURSING FACILITY 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:
AVANTARA PIERRE
Provider Other Organization Name Type Code:
3
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:
1528624681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 OAKTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60076-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-679-9797
Provider Business Mailing Address Fax Number:
847-679-1126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 E PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIERRE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57501-4154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-224-8628
Provider Business Practice Location Address Fax Number:
605-224-6948
Provider Enumeration Date:
05/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
RAJCHENBACH
Authorized Official First Name:
CHAIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PRINCIPAL
Authorized Official Telephone Number:
847-679-9797

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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