Healthcare Provider Details

I. General information

NPI: 1336504117
Provider Name (Legal Business Name): LAKE FOREST PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 10/08/2021
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PEMBRIDGE DR
LAKE FOREST IL
60045-4228
US

IV. Provider business mailing address

1100 PEMBRIDGE DR
LAKE FOREST IL
60045-4228
US

V. Phone/Fax

Practice location:
  • Phone: 847-604-6700
  • Fax: 847-979-3969
Mailing address:
  • Phone: 847-437-6700
  • Fax: 847-316-8723

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: MARK HAVRILKA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 847-979-3904