1639520034 NPI number — LUTHER OAKS INC

Table of content: (NPI 1639520034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639520034 NPI number — LUTHER OAKS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUTHER OAKS INC
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:
LUTHERAN SENIOR LIVING OF ILLINOIS
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:
1639520034
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 LUTZ RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61704-8608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-664-5940
Provider Business Mailing Address Fax Number:
309-664-5999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 LUTZ RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61704-8608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-664-5940
Provider Business Practice Location Address Fax Number:
309-664-5999
Provider Enumeration Date:
06/27/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PAULSBERG
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
847-368-7300

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)