Provider Demographics
NPI:1447425905
Name:PALOS HILLS EXTENDED CARE LLC
Entity type:Organization
Organization Name:PALOS HILLS EXTENDED CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-504-1234
Mailing Address - Street 1:642 ANTHONY TRL
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2540
Mailing Address - Country:US
Mailing Address - Phone:847-504-1234
Mailing Address - Fax:847-504-1203
Practice Address - Street 1:10426 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1932
Practice Address - Country:US
Practice Address - Phone:847-504-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL145650314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6046501Medicaid