Healthcare Provider Details

I. General information

NPI: 1487927968
Provider Name (Legal Business Name): WINDSOR PARK NURSING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2649 E 75TH ST
CHICAGO IL
60649-3835
US

IV. Provider business mailing address

2649 E 75TH ST
CHICAGO IL
60649-3835
US

V. Phone/Fax

Practice location:
  • Phone: 773-356-9300
  • Fax:
Mailing address:
  • Phone: 773-356-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number057003496
License Number StateIL

VIII. Authorized Official

Name: MRS. ONUWA JULIET EJECHI
Title or Position: OTA
Credential: COTA/L
Phone: 17733569300