Basic Information
| Provider Information | |||||||||
| NPI: | 1558355842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESENCE SENIOR SERVICES CHICAGOLAND | ||||||||
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| OtherOrganizationName: | PRESENCE SAINT BENEDICT NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18927 HICKORY CREEK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084786382 | ||||||||
| FaxNumber: | 7084785387 | ||||||||
| Practice Location | |||||||||
| Address1: | 6930 W TOUHY AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607144522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476470003 | ||||||||
| FaxNumber: | 8476471936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRUMMEY | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | LEAD CONTRACT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3144415866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0044784 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5407 | 01 | BLUE CROSS | OTHER |