Healthcare Provider Details

I. General information

NPI: 1568458693
Provider Name (Legal Business Name): PRESENCE LIFE CONNECTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BRIARCLIFF LN
BOURBONNAIS IL
60914-1665
US

IV. Provider business mailing address

18927 HICKORY CREEK DR STE 300
MOKENA IL
60448-8652
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-2022
  • Fax: 815-936-3231
Mailing address:
  • Phone: 708-478-7911
  • Fax: 708-478-5324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL GORDON
Title or Position: CFO
Credential:
Phone: 708-478-7911