Healthcare Provider Details

I. General information

NPI: 1023003092
Provider Name (Legal Business Name): ELMHURST EXTENDED CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E LAKE ST
ELMHURST IL
60126-2013
US

IV. Provider business mailing address

200 E LAKE ST
ELMHURST IL
60126-2013
US

V. Phone/Fax

Practice location:
  • Phone: 630-834-4337
  • Fax: 630-834-0480
Mailing address:
  • Phone: 630-834-4337
  • Fax: 630-834-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1636066
License Number StateIL

VIII. Authorized Official

Name: JOHN MASSARD
Title or Position: ADMINSTRATOR
Credential: LNHA
Phone: 630-834-4337