Healthcare Provider Details

I. General information

NPI: 1508074667
Provider Name (Legal Business Name): WOOD GLEN PAVILION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7444 LONG AVE
SKOKIE IL
60077-3214
US

IV. Provider business mailing address

201 W NORTH AVE
WEST CHICAGO IL
60185-6224
US

V. Phone/Fax

Practice location:
  • Phone: 847-329-4100
  • Fax:
Mailing address:
  • Phone: 630-876-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0043935
License Number StateIL

VIII. Authorized Official

Name: MR. BEN KLEIN
Title or Position: MANAGER
Credential:
Phone: 847-329-4100