Basic Information
| Provider Information | |||||||||
| NPI: | 1487821260 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VICTORY CENTRE OF RIVER WOODS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 RIVERWOODS DR | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085475800 | ||||||||
| FaxNumber: | 7083457458 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 RIVERWOODS DR | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085475800 | ||||||||
| FaxNumber: | 7083457458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2008 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAUM | ||||||||
| AuthorizedOfficialFirstName: | ELLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7085475800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PATHWAY SENIOR LIVING LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 364273297004 | IL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 364273297004 | 05 | IL | MEDICAID |