Healthcare Provider Details

I. General information

NPI: 1821604125
Provider Name (Legal Business Name): KINDRED CHICAGO NORTHLAKE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2544 W MONTROSE AVE
CHICAGO IL
60618-1537
US

IV. Provider business mailing address

2544 W MONTROSE AVE
CHICAGO IL
60618-1537
US

V. Phone/Fax

Practice location:
  • Phone: 773-267-2622
  • Fax: 773-267-2685
Mailing address:
  • Phone: 773-267-2622
  • Fax: 773-267-2685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: KATHY TEAGUE
Title or Position: VICE PRESIDENT, CORPORATE SECRETARY
Credential:
Phone: 629-253-5121