Basic Information
Provider Information | |||||||||
NPI: | 1720416787 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRENTWOOD OPERATING COMPANY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRENTWOOD SUB-ACUTE HEALTHCARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5400 W 87TH ST | ||||||||
Address2: |   | ||||||||
City: | BURBANK | ||||||||
State: | IL | ||||||||
PostalCode: | 604592913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5400 W 87TH ST | ||||||||
Address2: |   | ||||||||
City: | BURBANK | ||||||||
State: | IL | ||||||||
PostalCode: | 604592913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084231200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2013 | ||||||||
LastUpdateDate: | 04/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANTORO | ||||||||
AuthorizedOfficialFirstName: | KELLE | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | SVP - OPERATIONS FINANCE | ||||||||
AuthorizedOfficialTelephone: | 8324675728 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.