Healthcare Provider Details

I. General information

NPI: 1679578041
Provider Name (Legal Business Name): GENERATIONS AT COLUMBUS PARK,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S AUSTIN BLVD
CHICAGO IL
60644-5304
US

IV. Provider business mailing address

6840 N LINCOLN AVE
LINCOLNWOOD IL
60712-2628
US

V. Phone/Fax

Practice location:
  • Phone: 773-287-5959
  • Fax: 773-287-7909
Mailing address:
  • Phone: 847-675-7979
  • Fax: 847-674-5267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0037960
License Number StateIL

VIII. Authorized Official

Name: MR. THOMAS WINTER
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA
Phone: 847-675-7979