Healthcare Provider Details

I. General information

NPI: 1376362111
Provider Name (Legal Business Name): PRIME HEALTHCARE LIVING - HERITAGE VILLAGE - LODGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SPRINGFIELD AVE
JOLIET IL
60435-6589
US

IV. Provider business mailing address

210 SPRINGFIELD AVE
JOLIET IL
60435-6589
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-3400
  • Fax:
Mailing address:
  • Phone: 815-725-3400
  • 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: CHRISTOPHER DOAN
Title or Position: MANAGING ASSOCIATE GENERAL COUNSEL
Credential:
Phone: 310-259-4706