1922575752 NPI number — SOUTH HOLLAND MANOR HRC LLC

Table of content: (NPI 1922575752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922575752 NPI number — SOUTH HOLLAND MANOR HRC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH HOLLAND MANOR HRC 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:
SOUTH HOLLAND MANOR HEALTH & REHAB CENTER
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:
1922575752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60202-1519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-905-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2145 E 170TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH HOLLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60473-3788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-895-3255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/30/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ROTHNER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
847-905-4000

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)

  • Identifier: 0055053 . This is a "IL DEPARTMENT OF PUBLIC HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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