Basic Information
| Provider Information | |||||||||
| NPI: | 1881355345 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHWAY LA GRANGE PROPERTY OWNER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 S RIVERSIDE PLZ FL 20 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606065808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128370701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35 SHAWMUT AVE | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605258648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082069899 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2022 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | BECHT | ||||||||
| AuthorizedOfficialFirstName: | KRISTENJ | ||||||||
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| AuthorizedOfficialTitleorPosition: | RISK MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3128370710 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 5107393 | 01 | IL | IDPH LICENSE NUMBER | OTHER |