Healthcare Provider Details

I. General information

NPI: 1710003421
Provider Name (Legal Business Name): VIRGIL L CALVERT CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 SUMMIT AVE
EAST SAINT LOUIS IL
62203-1026
US

IV. Provider business mailing address

7434 SKOKIE BLVD
SKOKIE IL
60077-3341
US

V. Phone/Fax

Practice location:
  • Phone: 618-874-3597
  • Fax: 618-874-0240
Mailing address:
  • Phone: 847-982-2300
  • Fax: 847-982-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number25398644
License Number StateIL

VIII. Authorized Official

Name: MR. MOSHE HERMAN
Title or Position: COMPTROLLER
Credential:
Phone: 847-982-2300