=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073714341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARBOUR HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1512 W FARGO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-465-7751
-----------------------------------------------------
Fax | 773-465-2104
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1512 W FARGO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-465-7751
-----------------------------------------------------
Fax | 773-465-2104
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DEBRA L PATTY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-465-7751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 21767
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------