Basic Information
| Provider Information | |||||||||
| NPI: | 1154594299 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHCH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLONIAL HALL CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7444 LONG AVE | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600773214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473294100 | ||||||||
| FaxNumber: | 8473294900 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 S BUREAU VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613562203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158753347 | ||||||||
| FaxNumber: | 8158752012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 04/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | RUNGEE | ||||||||
| AuthorizedOfficialFirstName: | MARALEE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8473294100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0049510 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 14-5437 | 01 | MEDICARE | OTHER |