Basic Information
Provider Information | |||||||||
NPI: | 1376863019 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VILLA AT WINDSOR PARK NURSING AND LIVING CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7040 N RIDGEWAY AVE | ||||||||
Address2: |   | ||||||||
City: | LINCOLNWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 607122620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476799797 | ||||||||
FaxNumber: | 8476791126 | ||||||||
Practice Location | |||||||||
Address1: | 2649 E 75TH ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606493835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7733569300 | ||||||||
FaxNumber: | 7733569384 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2010 | ||||||||
LastUpdateDate: | 04/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERGER | ||||||||
AuthorizedOfficialFirstName: | MENACHEM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8476799797 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | LICENSE APPLIED FOR |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.