Basic Information
| Provider Information | |||||||||
| NPI: | 1962613828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GODFREY HEALTHCARE & REHABILITATION CENTER LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INTEGRITY HEALTHCARE OF GODFREY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4213 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084262315 | ||||||||
| FaxNumber: | 7082360001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1623 W DELMAR AVE | ||||||||
| Address2: | |||||||||
| City: | GODFREY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620351317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184660443 | ||||||||
| FaxNumber: | 6184661597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLISKO | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REP | ||||||||
| AuthorizedOfficialTelephone: | 7084262315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1794964 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 205779699 | 05 | IL | MEDICAID |