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General NPI Number Information
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NPI Number | 1093704165
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Entity Type | Organization
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Legal Business Name | WOODBINE NURSING HOME LLC
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Dates
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Enumeration Date | 10/20/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6909 NORTH AVE
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City | OAK PARK
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State | IL
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Zip | 60302-1008
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Country | US
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Telephone | 708-386-1112
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Fax | 708-524-4818
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Provider Business Mailing Address
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Address Line | 4055 W PETERSON AVE SUITE 101
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City | CHICAGO
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State | IL
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Zip | 60646-6182
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Country | US
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Telephone | 773-202-0000
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Fax | 773-267-0111
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Authorized Official
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Title or Position | CFO
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Name | MR. BARAK BAVER
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Credential |
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Telephone | 773-202-0000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 0044446
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License Number State | IL
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