Basic Information
| Provider Information | |||||||||
| NPI: | 1417622705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNOVATIVE SENIOR CARE HOME HEALTH OF CHICAGO, LLC | ||||||||
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| OtherOrganizationName: | BROOKDALE THERAPY OAK PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3374434154 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 ONTARIO ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603021939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089347149 | ||||||||
| FaxNumber: | 7089347148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2021 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GACHASSIN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INNOVATIVE SENIOR CARE HOME HEALTH OF CHICAGO, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.