Healthcare Provider Details

I. General information

NPI: 1710594353
Provider Name (Legal Business Name): CITADEL OF BOURBONNAIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BRIARCLIFF LN
BOURBONNAIS IL
60914-1665
US

IV. Provider business mailing address

3755 CHASE AVE
SKOKIE IL
60076-4008
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-2022
  • Fax: 815-936-3231
Mailing address:
  • Phone: 224-470-2044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARCELLA GRAF
Title or Position: CFO
Credential:
Phone: 224-470-2044