Healthcare Provider Details

I. General information

NPI: 1427048826
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 PARKVIEW AVE
ROCKFORD IL
61107-1899
US

IV. Provider business mailing address

1001 E TOUHY AVE
DES PLAINES IL
60018-5817
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-8832
  • Fax: 815-399-8342
Mailing address:
  • Phone: 847-635-4600
  • Fax: 847-390-1426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0021238
License Number StateIL

VIII. Authorized Official

Name: MR. GERALD EDMUND NOONDUV
Title or Position: VP FINANCE CFO
Credential:
Phone: 847-635-4600