Basic Information
Provider Information | |||||||||
NPI: | 1174525422 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE OPERATIONS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROVIDENCE PALOS HEIGHTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18601 N CREEK DR | ||||||||
Address2: |   | ||||||||
City: | TINLEY PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 604776397 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083428100 | ||||||||
FaxNumber: | 7083428006 | ||||||||
Practice Location | |||||||||
Address1: | 13259 S CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | PALOS HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 604632601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7085971000 | ||||||||
FaxNumber: | 7085971000 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2005 | ||||||||
LastUpdateDate: | 09/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZANDSTRA | ||||||||
AuthorizedOfficialFirstName: | JOHANNA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7083428137 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0028605 | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 362382853002 | 05 | IL |   | MEDICAID |