Basic Information
| Provider Information | |||||||||
| NPI: | 1730712886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOK ROAD AAL LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W WACKER DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606011781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122393534 | ||||||||
| FaxNumber: | 3124881919 | ||||||||
| Practice Location | |||||||||
| Address1: | 3731 W COOK RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468189403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604902112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2020 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | COCAGNE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3122393534 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.