Provider Demographics
NPI:1871580126
Name:4621 CORPORATION
Entity type:Organization
Organization Name:4621 CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:312-787-9400
Mailing Address - Street 1:405 N WABASH AVE STE P2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3541
Mailing Address - Country:US
Mailing Address - Phone:312-787-9400
Mailing Address - Fax:312-787-9434
Practice Address - Street 1:4621 N RACINE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4905
Practice Address - Country:US
Practice Address - Phone:773-784-2300
Practice Address - Fax:773-769-4621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0023770314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid