Healthcare Provider Details

I. General information

NPI: 1598188237
Provider Name (Legal Business Name): LONG GROVE PAC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 RFD
LONG GROVE IL
60047-7368
US

IV. Provider business mailing address

7040 N RIDGEWAY AVE
LINCOLNWOOD IL
60712-2620
US

V. Phone/Fax

Practice location:
  • Phone: 847-419-1111
  • Fax: 847-419-1119
Mailing address:
  • Phone: 847-679-9797
  • Fax: 847-676-5348

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: YAIR ZUCKERMAN
Title or Position: COO
Credential:
Phone: 847-679-9797