1730173048 NPI number — PRESENCE SENIOR SERVICES CHICAGOLAND

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 1730173048 NPI number — PRESENCE SENIOR SERVICES CHICAGOLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESENCE SENIOR SERVICES CHICAGOLAND
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:
1730173048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18927 HICKORY CREEK DR
Provider Second Line Business Mailing Address:
SUITE #300
Provider Business Mailing Address City Name:
MOKENA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60448-8590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-478-6382
Provider Business Mailing Address Fax Number:
708-478-6387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 N GREENWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60068-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-692-5600
Provider Business Practice Location Address Fax Number:
847-692-2305
Provider Enumeration Date:
09/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GRONEFELD
Authorized Official First Name:
KELLIE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
314-729-3500

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0044362 , 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: 5411 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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