Healthcare Provider Details

I. General information

NPI: 1578321311
Provider Name (Legal Business Name): 17400 S KEDZIE AVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 KEDZIE AVE
HAZEL CREST IL
60429-1600
US

IV. Provider business mailing address

17400 KEDZIE AVE
HAZEL CREST IL
60429-1600
US

V. Phone/Fax

Practice location:
  • Phone: 618-780-3256
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY PETERSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 813-415-7589