Basic Information
| Provider Information | |||||||||
| NPI: | 1184626434 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE DOWNERS GROVE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18601 NORTH CREEK DRIVE | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083428100 | ||||||||
| FaxNumber: | 7083428006 | ||||||||
| Practice Location | |||||||||
| Address1: | 3450 SARATOGA AVE | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309692900 | ||||||||
| FaxNumber: | 6309692900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | ZANDSTRA | ||||||||
| AuthorizedOfficialFirstName: | JOHANNA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7083428137 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | 362382853003 | 05 | IL | MEDICAID |