Basic Information
Provider Information | |||||||||
NPI: | 1225022510 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRESENCE SENIOR SERVICES CHICAGOLAND | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRESENCE MARYHAVEN NURSING AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 E LAKE AVE | ||||||||
Address2: |   | ||||||||
City: | GLENVIEW | ||||||||
State: | IL | ||||||||
PostalCode: | 600252003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8477291300 | ||||||||
FaxNumber: | 8477299620 | ||||||||
Practice Location | |||||||||
Address1: | 1700 EAST LAKE AVE | ||||||||
Address2: |   | ||||||||
City: | GLENVIEW | ||||||||
State: | IL | ||||||||
PostalCode: | 60025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8477291300 | ||||||||
FaxNumber: | 8477299620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2005 | ||||||||
LastUpdateDate: | 05/24/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GORDON | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7084787911 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0044768 | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 50038 | 01 |   | BLUE CROSS | OTHER |