Basic Information
| Provider Information | |||||||||
| NPI: | 1780661348 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WARREN PARK NURSING PAVILION, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3359 MAIN ST | ||||||||
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| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476798219 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6700 N DAMEN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606454902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734655000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2005 | ||||||||
| LastUpdateDate: | 08/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | MAUER | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8476798219 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0036079 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.