Basic Information
| Provider Information | |||||||||
| NPI: | 1275903601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEISURE TERRACE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8153 LAWNDALE AVE | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600763321 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5211 W 103RD ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662073154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133832569 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2015 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | SHIMON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER/MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7739451107 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.