Basic Information
| Provider Information | |||||||||
| NPI: | 1568413821 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAUKEGAN TERRACE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | LAKE PARK CENTER,LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479339200 | ||||||||
| FaxNumber: | 8476745794 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 WASHINGTON PARK | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600857258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476239100 | ||||||||
| FaxNumber: | 8476239179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEINFELD | ||||||||
| AuthorizedOfficialFirstName: | AVRUM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CE0 | ||||||||
| AuthorizedOfficialTelephone: | 8476745795 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 0027052 | IL | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 310500000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 0054304 | 05 | IL | MEDICAID |