Healthcare Provider Details

I. General information

NPI: 1023677184
Provider Name (Legal Business Name): ALDEN ESTATES OF COUNTRYSIDE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 COLLINS RD
JEFFERSON WI
53549-2939
US

IV. Provider business mailing address

4200 W PETERSON AVE
CHICAGO IL
60646-6074
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-3170
  • Fax:
Mailing address:
  • Phone: 773-724-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: JOHN AVELINO
Title or Position: ACCOUNTS RECEIVABLE MANAGER
Credential:
Phone: 773-724-6376