Healthcare Provider Details

I. General information

NPI: 1922987429
Provider Name (Legal Business Name): HAVEN OF WABASH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S 2ND ST
GRAYVILLE IL
62844-1527
US

IV. Provider business mailing address

2201 MAIN ST
EVANSTON IL
60202-1519
US

V. Phone/Fax

Practice location:
  • Phone: 618-375-1371
  • Fax:
Mailing address:
  • Phone: 773-989-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. LEVI ISRAEL
Title or Position: CEO
Credential:
Phone: 847-905-3283