Healthcare Provider Details

I. General information

NPI: 1902003221
Provider Name (Legal Business Name): FAIRVIEW CARE CENTER OF LAGRANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3553 W PETERSON AVE
CHICAGO IL
60659-3200
US

IV. Provider business mailing address

3553 W PETERSON AVE
CHICAGO IL
60659-3200
US

V. Phone/Fax

Practice location:
  • Phone: 773-509-0027
  • 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 StateIL

VIII. Authorized Official

Name: YOSEF MEYSTEL
Title or Position: MANAGER
Credential:
Phone: 773-509-0027