Healthcare Provider Details

I. General information

NPI: 1477530426
Provider Name (Legal Business Name): PARK RIDGE CARE CENTER, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 BUSSE HWY
PARK RIDGE IL
60068-2523
US

IV. Provider business mailing address

3359 MAIN ST
SKOKIE IL
60076-2432
US

V. Phone/Fax

Practice location:
  • Phone: 847-825-5517
  • Fax: 847-825-5596
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0039255
License Number StateIL

VIII. Authorized Official

Name: MR. MARSHALL A MAUER
Title or Position: ASST SECRETARY
Credential:
Phone: 847-679-8219