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General NPI Number Information
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NPI Number | 1174525422
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Entity Type | Organization
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Legal Business Name | PROVIDENCE OPERATIONS, LLC
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Dates
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Enumeration Date | 06/01/2005
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Last Update Date | 09/23/2015
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Provider Practice Location Address
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Address Line | 13259 S CENTRAL AVE
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-2601
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Country | US
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Telephone | 708-597-1000
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Fax | 708-597-1000
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Provider Business Mailing Address
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Address Line | 18601 N CREEK DR
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City | TINLEY PARK
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State | IL
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Zip | 60477-6397
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Country | US
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Telephone | 708-342-8100
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Fax | 708-342-8006
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Authorized Official
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Title or Position | COMPLIANCE OFFICER
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Name | MRS. JOHANNA R ZANDSTRA
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Credential |
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Telephone | 708-342-8137
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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 | 0028605
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License Number State | IL
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