MEDICARE: HICKORY NURSING PAVILION

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	0032029	IL

General Provider Information

NPI Number	:	1710971288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HICKORY NURSING PAVILION

Provider Business Mailing Address
First Line	:	3737 W ARTHUR AVE
Second Line	:
City	:	LINCOLNWOOD
State	:	IL
Zip	:	60712-4029
Country	:	US
Telephone Number	:	847-679-2121
Fax Number	:	847-679-2122

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	:	OWNER
Name	:	MR. HOWARD WENGROW
Credential	:
Telephone Number	:	708-598-4040

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	06/02/2016

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