Healthcare Provider Details

I. General information

NPI: 1174525422
Provider Name (Legal Business Name): PROVIDENCE OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13259 S CENTRAL AVE
PALOS HEIGHTS IL
60463-2601
US

IV. Provider business mailing address

18601 N CREEK DR
TINLEY PARK IL
60477-6397
US

V. Phone/Fax

Practice location:
  • Phone: 708-597-1000
  • Fax: 708-597-1000
Mailing address:
  • Phone: 708-342-8100
  • Fax: 708-342-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0028605
License Number StateIL

VIII. Authorized Official

Name: MRS. JOHANNA R ZANDSTRA
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 708-342-8137