Healthcare Provider Details

I. General information

NPI: 1215921622
Provider Name (Legal Business Name): MOMENCE MEADOWS NURSING & REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S WALNUT ST
MOMENCE IL
60954-1814
US

IV. Provider business mailing address

500 S WALNUT
MOMENCE IL
60954
US

V. Phone/Fax

Practice location:
  • Phone: 815-472-2423
  • Fax: 815-472-6212
Mailing address:
  • Phone: 815-472-2423
  • Fax: 815-472-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0028480
License Number StateIL

VIII. Authorized Official

Name: MOISHE GUBIN
Title or Position: OWNER
Credential:
Phone: 815-472-2423