Basic Information
| Provider Information | |||||||||
| NPI: | 1922746577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAVILION OF SOUTH SHORE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3755 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600764008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2244702044 | ||||||||
| FaxNumber: | 2244702952 | ||||||||
| Practice Location | |||||||||
| Address1: | 7750 S SOUTH SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606494434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737314200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRAF | ||||||||
| AuthorizedOfficialFirstName: | MARCELLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2244702044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 6009757 | 05 | IL | MEDICAID |