Basic Information
| Provider Information | |||||||||
| NPI: | 1487841649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VICTORY CENTRE OF PARK FOREST LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 W. WACKER DRIVE | ||||||||
| Address2: | SUITE 1010 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606061202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128370701 | ||||||||
| FaxNumber: | 3128370728 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PARK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604662375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082832921 | ||||||||
| FaxNumber: | 7082838364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 07/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | FINIS | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3128370704 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PSL HOLDINGS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | IL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 364270870001 | 05 | IL | MEDICAID |