MEDICARE: HICKORY VILLAGE NURSING AND REHABILITATION CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1417688649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HICKORY VILLAGE NURSING AND REHABILITATION CENTER LLC

Provider Business Mailing Address
First Line	:	8707 SKOKIE BLVD
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-2269
Country	:	US
Telephone Number	:	773-896-6723
Fax Number	:

Provider Business Practice Location Address
First Line	:	9246 S ROBERTS RD
Second Line	:
City	:	HICKORY HILLS
State	:	IL
Zip	:	60457-2066
Country	:	US
Telephone Number	:	708-598-4040
Fax Number	:	708-598-3796

Authorized Official
Title or Position	:	MEMBER
Name	:	DAVID MASHIACH
Credential	:
Telephone Number	:	773-896-6723

Provider Enumeration Date	:	06/20/2022
Last Update Date	:	10/03/2022

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