Basic Information
| Provider Information | |||||||||
| NPI: | 1891454872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIA OF MASCOUTAH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479339200 | ||||||||
| FaxNumber: | 8479339765 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MASCOUTAH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622581017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185662183 | ||||||||
| FaxNumber: | 8479339765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2021 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | NATAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8479339200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.