Healthcare Provider Details

I. General information

NPI: 1285611830
Provider Name (Legal Business Name): WATERFRONT TERRACE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2005
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7750 S SOUTH SHORE DR
CHICAGO IL
60649-4434
US

IV. Provider business mailing address

3359 MAIN ST
SKOKIE IL
60076-2432
US

V. Phone/Fax

Practice location:
  • Phone: 773-731-4200
  • Fax:
Mailing address:
  • Phone: 847-679-8219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0028076
License Number StateIL

VIII. Authorized Official

Name: MR. MARSHALL A MAUER
Title or Position: SECRETARY-TREASURER
Credential:
Phone: 847-679-8219