Basic Information
| Provider Information | |||||||||
| NPI: | 1942297775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WENTWORTH REHABILITATION AND HEALTH CARE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 W PETERSON AVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606466074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732866622 | ||||||||
| FaxNumber: | 7732862150 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 W 69TH ST | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606213719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734871200 | ||||||||
| FaxNumber: | 7734874782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | AVELINO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCOUNTS RECIEVABLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7737246376 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 314000000X | 0026435 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1005 | 01 | IL | BLUE CROSS | OTHER |