Basic Information
| Provider Information | |||||||||
| NPI: | 1609173590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PH KENOSHA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENOSHA ESTATES LIVING AND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7444 LONG AVE | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600773214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473294100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1703 60TH ST | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531403986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626584125 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2011 | ||||||||
| LastUpdateDate: | 02/11/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8473294100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.