Basic Information
| Provider Information | |||||||||
| NPI: | 1013937309 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THI OF ILLINOIS AT EXCEPTIONAL HEALTH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EXCEPTIONAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5701 W 79TH ST | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084995400 | ||||||||
| FaxNumber: | 7084995472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7084995400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0046458 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 521979253001 | 05 | IL | MEDICAID |