Healthcare Provider Details

I. General information

NPI: 1427461292
Provider Name (Legal Business Name): AVANTARA PARK RIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 N WESTERN AVE
PARK RIDGE IL
60068-1233
US

IV. Provider business mailing address

7040 N RIDGEWAY AVE
LINCOLNWOOD IL
60712-2620
US

V. Phone/Fax

Practice location:
  • Phone: 847-825-5531
  • Fax: 847-316-6659
Mailing address:
  • Phone: 847-825-5531
  • Fax: 847-316-6659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. FRANCES MEEHAN
Title or Position: ATTORNEY
Credential:
Phone: 312-521-2467