Healthcare Provider Details

I. General information

NPI: 1205291457
Provider Name (Legal Business Name): THREE CROWNS PARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 MCDANIEL AVE
EVANSTON IL
60201-2549
US

IV. Provider business mailing address

2323 MCDANIEL AVE
EVANSTON IL
60201-2549
US

V. Phone/Fax

Practice location:
  • Phone: 847-328-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5102915
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0012773
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0012773
License Number StateIL

VIII. Authorized Official

Name: PHILIP HEMMER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 847-328-8700