Healthcare Provider Details

I. General information

NPI: 1609843754
Provider Name (Legal Business Name): WASHINGTON AND JANE SMITH COMMUNITY BEVERLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11308 S OAKLEY AVE
CHICAGO IL
60643-4112
US

IV. Provider business mailing address

2320 W 113TH PL
CHICAGO IL
60643-4117
US

V. Phone/Fax

Practice location:
  • Phone: 773-474-7300
  • Fax: 773-474-7342
Mailing address:
  • Phone: 773-474-7300
  • Fax: 773-474-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0015032
License Number StateIL

VIII. Authorized Official

Name: MR. RAYMOND MARNERIS
Title or Position: CFO
Credential:
Phone: 773-474-7350