Healthcare Provider Details

I. General information

NPI: 1336907179
Provider Name (Legal Business Name): FULLERTON SKILLED NURSING FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1366 W FULLERTON AVE
CHICAGO IL
60614-2129
US

IV. Provider business mailing address

3450 OAKTON ST
SKOKIE IL
60076-2951
US

V. Phone/Fax

Practice location:
  • Phone: 773-844-8880
  • Fax:
Mailing address:
  • Phone: 773-844-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MENACHEM SHABAT
Title or Position: PRESIDENT
Credential:
Phone: 847-679-5331