Basic Information
| Provider Information | |||||||||
| NPI: | 1598188237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONG GROVE PAC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVANTARA LONG GROVE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7040 N RIDGEWAY AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLNWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607122620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476799797 | ||||||||
| FaxNumber: | 8476765348 | ||||||||
| Practice Location | |||||||||
| Address1: | 1666 RFD | ||||||||
| Address2: | |||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600477368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474191111 | ||||||||
| FaxNumber: | 8474191119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2014 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | ZUCKERMAN | ||||||||
| AuthorizedOfficialFirstName: | YAIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8476799797 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.