Basic Information
| Provider Information | |||||||||
| NPI: | 1912411174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY SKILLED NURSING FACILITY LLC | ||||||||
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| OtherOrganizationName: | AVANTARA OF CAMERON PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1807 24TH ST W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066565010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2017 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | SHABAT | ||||||||
| AuthorizedOfficialFirstName: | MENACHEM | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8476799797 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.