Healthcare Provider Details

I. General information

NPI: 1902098239
Provider Name (Legal Business Name): IMPERIAL MANOR OF HAZEL CREST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 175TH ST
HAZEL CREST IL
60429-1604
US

IV. Provider business mailing address

3300 175TH ST
HAZEL CREST IL
60429-1604
US

V. Phone/Fax

Practice location:
  • Phone: 708-335-2400
  • Fax: 708-335-1825
Mailing address:
  • Phone: 708-335-2400
  • Fax: 708-335-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0040402
License Number StateIL

VIII. Authorized Official

Name: MR. MARK STEINBERG
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 847-905-3000