Healthcare Provider Details

I. General information

NPI: 1376960039
Provider Name (Legal Business Name): KING-BRUWAERT HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 S COUNTY LINE RD
BURR RIDGE IL
60527-8132
US

IV. Provider business mailing address

6101 S COUNTY LINE RD
BURR RIDGE IL
60527-8132
US

V. Phone/Fax

Practice location:
  • Phone: 630-323-2250
  • Fax: 630-655-8179
Mailing address:
  • Phone: 630-323-2250
  • Fax: 630-655-8179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0002584
License Number StateIL

VIII. Authorized Official

Name: CARL BAKER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 630-230-9502