Healthcare Provider Details

I. General information

NPI: 1982946604
Provider Name (Legal Business Name): ADMIRAL AT THE LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 07/17/2023
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 W. FOSTER AVE
CHICAGO IL
60640
US

IV. Provider business mailing address

929 W FOSTER AVE
CHICAGO IL
60640-1491
US

V. Phone/Fax

Practice location:
  • Phone: 773-433-1800
  • Fax:
Mailing address:
  • Phone: 773-433-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHAIM DUBOVICK
Title or Position: ADMINISTRATOR
Credential:
Phone: 773-433-1800