Healthcare Provider Details

I. General information

NPI: 1407519333
Provider Name (Legal Business Name): HYDE PARK VILLAGE NURSING & REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 S DREXEL BLVD
CHICAGO IL
60653-4301
US

IV. Provider business mailing address

4505 S DREXEL BLVD
CHICAGO IL
60653-4301
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID MASHIACH
Title or Position: MEMBER
Credential:
Phone: 312-791-0035