Healthcare Provider Details

I. General information

NPI: 1821355561
Provider Name (Legal Business Name): LTC PRACTITIONERS OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 N. KENNETH AVE.
CHICAGO IL
60641-2816
US

IV. Provider business mailing address

3915 N KENNETH AVE
CHICAGO IL
60641-2816
US

V. Phone/Fax

Practice location:
  • Phone: 773-401-4412
  • Fax: 312-492-6269
Mailing address:
  • Phone: 773-401-4412
  • Fax: 312-492-6269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number209009340
License Number StateIL

VIII. Authorized Official

Name: SUE E. WILSON
Title or Position: NURSE PRACTITIONER
Credential: APN
Phone: 773-401-4412