Healthcare Provider Details

I. General information

NPI: 1942608203
Provider Name (Legal Business Name): COMMUNITY FIRST HEALTHCARE OF ILLINOIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 W ADDISON ST
CHICAGO IL
60634-4403
US

IV. Provider business mailing address

5645 W ADDISON ST
CHICAGO IL
60634-4403
US

V. Phone/Fax

Practice location:
  • Phone: 773-282-7000
  • Fax: 773-527-5900
Mailing address:
  • Phone: 773-282-7000
  • Fax: 773-527-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0001719
License Number StateIL

VIII. Authorized Official

Name: EDWARD JOSEPH GREEN
Title or Position: OWNER/LEGAL COUNSEL
Credential:
Phone: 312-832-4375