Basic Information
| Provider Information | |||||||||
| NPI: | 1164633657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
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| OtherOrganizationName: | SHADY OAKS WEST | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E TOUHY AVE | ||||||||
| Address2: | SUITE# 170 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600185801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476354600 | ||||||||
| FaxNumber: | 8472973407 | ||||||||
| Practice Location | |||||||||
| Address1: | 16220 S PARKER RD | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604919081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083010571 | ||||||||
| FaxNumber: | 7083010573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | NOONAN | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8476354600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 0040527 | IL | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.