Healthcare Provider Details

I. General information

NPI: 1285630723
Provider Name (Legal Business Name): BM OF CHICAGO RIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10602 SOUTHWEST HWY
CHICAGO RIDGE IL
60415-1429
US

IV. Provider business mailing address

6500 N HAMLIN AVE
LINCOLNWOOD IL
60712-3904
US

V. Phone/Fax

Practice location:
  • Phone: 708-448-1540
  • Fax:
Mailing address:
  • Phone: 847-679-7484
  • Fax: 847-679-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number000045815
License Number StateIL

VIII. Authorized Official

Name: MR. DAVID LUBOWSKY
Title or Position: BOOKKEEPER
Credential:
Phone: 847-679-7484