Healthcare Provider Details

I. General information

NPI: 1669887394
Provider Name (Legal Business Name): ESTATES OF HYDE PARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 S DREXEL BLVD
CHICAGO IL
60653-4301
US

IV. Provider business mailing address

1406 WESTCHESTER RD
BUFFALO GROVE IL
60089-6880
US

V. Phone/Fax

Practice location:
  • Phone: 773-285-0550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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. JOSHUA DAVID LEGUM
Title or Position: MEMBER
Credential:
Phone: 516-410-5209