Basic Information
| Provider Information | |||||||||
| NPI: | 1942608203 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY FIRST HEALTHCARE OF ILLINOIS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY FIRST MEDICAL CENTER SKILLED NURSING UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 W ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606344403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732827000 | ||||||||
| FaxNumber: | 7735275900 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 W ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606344403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732827000 | ||||||||
| FaxNumber: | 7735275900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2014 | ||||||||
| LastUpdateDate: | 12/18/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/LEGAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 3128324375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0001719 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.