Healthcare Provider Details

I. General information

NPI: 1124173844
Provider Name (Legal Business Name): EAST BANK CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6131 PARK RIDGE RD
LOVES PARK IL
61111-4029
US

IV. Provider business mailing address

12040 RAYMOND CT
HUNTLEY IL
60142-8069
US

V. Phone/Fax

Practice location:
  • Phone: 815-633-6810
  • Fax: 815-633-5095
Mailing address:
  • Phone: 847-515-1505
  • Fax: 847-515-1503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0047209
License Number StateIL

VIII. Authorized Official

Name: MISS EDNA L LOPEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 815-633-6810