Healthcare Provider Details

I. General information

NPI: 1497957997
Provider Name (Legal Business Name): WALNUT GROVE VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 W PETERSON AVE SUITE 101
CHICAGO IL
60646-6182
US

IV. Provider business mailing address

1095 TWILIGHT DR
MORRIS IL
60450-3305
US

V. Phone/Fax

Practice location:
  • Phone: 773-202-0000
  • Fax: 773-267-0111
Mailing address:
  • Phone: 815-942-5108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0033506
License Number StateIL

VIII. Authorized Official

Name: MR. BARAK BAVER
Title or Position: CFO
Credential:
Phone: 773-202-0000