Basic Information
| Provider Information | |||||||||
| NPI: | 1518540871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICAGO RIDGE SKILLED NURSING FACILITY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVANTARA CHICAGO RIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3450 OAKTON ST | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476799797 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10300 SOUTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604151426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084251100 | ||||||||
| FaxNumber: | 7084250779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2021 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | NINIO | ||||||||
| AuthorizedOfficialFirstName: | MORDECHAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8476765315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.