Healthcare Provider Details

I. General information

NPI: 1194860577
Provider Name (Legal Business Name): BOULEVARD CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 S MICHIGAN AVE
CHICAGO IL
60616-3819
US

IV. Provider business mailing address

8320 SKOKIE BLVD
SKOKIE IL
60077-2545
US

V. Phone/Fax

Practice location:
  • Phone: 312-791-0035
  • Fax:
Mailing address:
  • Phone: 847-329-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0032276
License Number StateIL

VIII. Authorized Official

Name: JENNIE SHAN-MARTIN
Title or Position: CONTROLLER
Credential:
Phone: 847-329-1555