1568461820 NPI number — REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME

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 1568461820 NPI number — REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
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:
Provider Other Organization Name Type Code:
6
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:
1568461820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14301 INDEPENDENCE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMER GLEN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60491-7210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-509-2800
Provider Business Mailing Address Fax Number:
708-877-4818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14301 INDEPENDENCE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMER GLEN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60491-7210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-509-2800
Provider Business Practice Location Address Fax Number:
708-877-4818
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ZANDSTRA
Authorized Official First Name:
JOHANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
708-342-8100

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1010138 , 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: 147559 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50070 . This is a "BC/BS PREFERRED PROVIDER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1010138 . This is a "IL DEPT. OF PUBLIC HEALT" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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