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General NPI Number Information
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NPI Number | 1114520210
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Entity Type | Organization
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Legal Business Name | FARGO HEALTH CARE CENTER LLC
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Dates
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Enumeration Date | 11/19/2020
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 1512 W FARGO AVE
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City | CHICAGO
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State | IL
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Zip | 60626-1805
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Country | US
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Telephone | 773-465-7751
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Fax |
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Provider Business Mailing Address
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Address Line | 3737 W ARTHUR AVE
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City | LINCOLNWOOD
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State | IL
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Zip | 60712-4029
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | AHARON DIENA
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Credential |
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Telephone | 773-465-2104
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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 |
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License Number State |
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