Healthcare Provider Details

I. General information

NPI: 1629340690
Provider Name (Legal Business Name): CC CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4314 S WABASH AVE
CHICAGO IL
60653-3119
US

IV. Provider business mailing address

4314 S WABASH AVE
CHICAGO IL
60653-3119
US

V. Phone/Fax

Practice location:
  • Phone: 773-538-8300
  • Fax: 773-538-5775
Mailing address:
  • Phone: 773-538-8300
  • Fax: 773-538-5775

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: MR. JAMIE NICKLE
Title or Position: DIRECTOR
Credential:
Phone: 630-501-0996