Healthcare Provider Details

I. General information

NPI: 1609396167
Provider Name (Legal Business Name): LITTLE VILLAGE NURSING AND REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 S LAWNDALE AVE
CHICAGO IL
60623-3154
US

IV. Provider business mailing address

2320 S LAWNDALE AVE
CHICAGO IL
60623-3154
US

V. Phone/Fax

Practice location:
  • Phone: 773-522-0400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number54643
License Number StateIL

VIII. Authorized Official

Name: DAVID MASHIACH
Title or Position: MANAGER
Credential:
Phone: 773-522-0400