Healthcare Provider Details

I. General information

NPI: 1568413821
Provider Name (Legal Business Name): WAUKEGAN TERRACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 WASHINGTON PARK
WAUKEGAN IL
60085-7258
US

IV. Provider business mailing address

5151 CHURCH ST
SKOKIE IL
60077-1123
US

V. Phone/Fax

Practice location:
  • Phone: 847-623-9100
  • Fax: 847-623-9179
Mailing address:
  • Phone: 847-933-9200
  • Fax: 847-674-5794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0027052
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. AVRUM WEINFELD
Title or Position: CFO
Credential:
Phone: 847-674-5795