Basic Information
| Provider Information | |||||||||
| NPI: | 1902462211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IPSWICH SD SKILLED NURSING FACILITY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3450 OAKTON ST | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476799797 | ||||||||
| FaxNumber: | 8476791126 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 BLOEMENDAAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | IPSWICH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054266622 | ||||||||
| FaxNumber: | 6054266565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2019 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHABAT | ||||||||
| AuthorizedOfficialFirstName: | MENACHEM | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/PRINCIPAL | ||||||||
| 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.