MEDICARE: WALNUT GROVE VILLAGE

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	0033506	IL

General Provider Information

NPI Number	:	1497957997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALNUT GROVE VILLAGE

Provider Business Mailing Address
First Line	:	1095 TWILIGHT DR
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-3305
Country	:	US
Telephone Number	:	815-942-5108
Fax Number	:

Provider Business Practice Location Address
First Line	:	4055 W PETERSON AVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60646-6182
Country	:	US
Telephone Number	:	773-202-0000
Fax Number	:	773-267-0111

Authorized Official
Title or Position	:	CFO
Name	:	MR. BARAK BAVER
Credential	:
Telephone Number	:	773-202-0000

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	08/22/2020

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Directions to “WALNUT GROVE VILLAGE ” Practice Location

Language	Start Address	Practice Location

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