Basic Information
| Provider Information | |||||||||
| NPI: | 1891780946 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVENA SENIOR SERVICES | ||||||||
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| OtherOrganizationName: | PROVENA GENEVA CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19065 HICKORY CREEK PL | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084787900 | ||||||||
| FaxNumber: | 7084785387 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 E STATE ST | ||||||||
| Address2: | PROVENA GENEVA CARE CENTER | ||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302327544 | ||||||||
| FaxNumber: | 6302324409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DR. PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3155062351 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVENA SENIOR SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.