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General NPI Number Information
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NPI Number | 1124020474
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Entity Type | Organization
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Legal Business Name | REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
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Dates
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Enumeration Date | 06/01/2005
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Last Update Date | 04/14/2009
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Provider Practice Location Address
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Address Line | 16300 WAUSAU AVE
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-2158
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Country | US
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Telephone | 708-596-5500
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Fax | 708-596-5527
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Provider Business Mailing Address
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Address Line | 16300 WAUSAU AVE
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-2158
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Country | US
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Telephone | 708-596-5500
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Fax | 708-596-5527
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Authorized Official
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Title or Position | VP OPERATIONAL SYSTEMS
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Name | MS. JOAN C MCCARTHY
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Credential |
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Telephone | 708-342-8179
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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 | 0023242
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License Number State | IL
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