Basic Information
| Provider Information | |||||||||
| NPI: | 1568458693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESENCE LIFE CONNECTIONS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRESENCE OUR LADY OF VICTORY NURSING HOME | ||||||||
| 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: | 7084787911 | ||||||||
| FaxNumber: | 7084785324 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 BRIARCLIFF LN | ||||||||
| Address2: | |||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609141665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159372022 | ||||||||
| FaxNumber: | 8159363231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 03/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7084787911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRESENCE LIFE CONNECTIONS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.