Basic Information
| Provider Information | |||||||||
| NPI: | 1902167349 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARE PROPCO LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | TERRACES AT THE CLARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 55 E PEARSON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129515690 | ||||||||
| FaxNumber: | 3127848016 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 E PEARSON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129515690 | ||||||||
| FaxNumber: | 3127848016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2012 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRIDGEWATER | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5158754500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.