Basic Information
| Provider Information | |||||||||
| NPI: | 1144981515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAND VICTORIAN OF ROCKFORD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 222 S RIVERSIDE PLZ FL 20 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606065808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128370701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3495 MCFARLAND RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611145609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156541400 | ||||||||
| FaxNumber: | 8158601764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2022 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECHT | ||||||||
| AuthorizedOfficialFirstName: | KRISTEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RISK MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3128370710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELL PATH TENANT, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 5107955 | 01 | IL | IDPH ASSISTED LIVING LICENSE | OTHER |