Healthcare Provider Details

I. General information

NPI: 1396024964
Provider Name (Legal Business Name): GROVE AT THE LAKE LIVING AND REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2534 ELIM AVE
ZION IL
60099-2661
US

IV. Provider business mailing address

7040 N RIDGEWAY AVE
LINCOLNWOOD IL
60712-2620
US

V. Phone/Fax

Practice location:
  • Phone: 847-746-8435
  • Fax:
Mailing address:
  • Phone: 847-679-9797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2019775
License Number StateIL

VIII. Authorized Official

Name: REUVEN LEVITIN
Title or Position: AR MANAGER
Credential:
Phone: 847-676-5307