Healthcare Provider Details

I. General information

NPI: 1891780946
Provider Name (Legal Business Name): PROVENA SENIOR SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E STATE ST PROVENA GENEVA CARE CENTER
GENEVA IL
60134-2438
US

IV. Provider business mailing address

19065 HICKORY CREEK PL SUITE 310
MOKENA IL
60448-8507
US

V. Phone/Fax

Practice location:
  • Phone: 630-232-7544
  • Fax: 630-232-4409
Mailing address:
  • Phone: 708-478-7900
  • Fax: 708-478-5387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. DENISE A NICHOLS
Title or Position: DR. PATIENT FINANCIAL SERVICES
Credential:
Phone: 315-506-2351