Healthcare Provider Details

I. General information

NPI: 1871580126
Provider Name (Legal Business Name): 4621 CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4621 N RACINE AVE
CHICAGO IL
60640-4905
US

IV. Provider business mailing address

405 N WABASH AVE STE P2W
CHICAGO IL
60611-3541
US

V. Phone/Fax

Practice location:
  • Phone: 773-784-2300
  • Fax: 773-769-4621
Mailing address:
  • Phone: 312-787-9400
  • Fax: 312-787-9434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0023770
License Number State

VIII. Authorized Official

Name: MR. PETER J OBRIEN SR.
Title or Position: PRESIDENT
Credential:
Phone: 312-787-9400