Healthcare Provider Details

I. General information

NPI: 1720031156
Provider Name (Legal Business Name): FOUNTAINS CRYSTAL LAKE SL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E BRIGHTON LN
CRYSTAL LAKE IL
60012-2074
US

IV. Provider business mailing address

965 N BRIGHTON CIR
CRYSTAL LAKE IL
60012-2036
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-8400
  • Fax: 815-477-6502
Mailing address:
  • Phone: 815-455-8400
  • Fax: 815-477-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0047217
License Number StateIL

VIII. Authorized Official

Name: GRETA FRUHLING FRAZIER
Title or Position: DIRECTOR
Credential:
Phone: 520-797-4000