Healthcare Provider Details

I. General information

NPI: 1881681245
Provider Name (Legal Business Name): BLOOMINGDALE PAVILION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 EDGEWATER DR
BLOOMINGDALE IL
60108-1979
US

IV. Provider business mailing address

311 EDGEWATER DR
BLOOMINGDALE IL
60108-1979
US

V. Phone/Fax

Practice location:
  • Phone: 630-894-7400
  • Fax: 630-894-8528
Mailing address:
  • Phone: 630-894-7400
  • Fax: 630-894-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number44347
License Number StateIL

VIII. Authorized Official

Name: MRS. JOSEPHINE SOLIS
Title or Position: MDS/CARE PLAN COORDINATOR
Credential: L.P.N.
Phone: 630-894-7400