Healthcare Provider Details

I. General information

NPI: 1942344007
Provider Name (Legal Business Name): LAKE COOK TERRACE NURSING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 SKOKIE BLVD
NORTHBROOK IL
60062-1611
US

IV. Provider business mailing address

263 SKOKIE BLVD
NORTHBROOK IL
60062-1611
US

V. Phone/Fax

Practice location:
  • Phone: 847-564-0505
  • Fax: 847-564-3775
Mailing address:
  • Phone: 847-564-0505
  • Fax: 847-564-3775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1773151
License Number StateIL

VIII. Authorized Official

Name: MRS. SHELLEY MARTINEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 847-564-0505