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General NPI Number Information
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NPI Number | 1205291457
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Entity Type | Organization
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Legal Business Name | THREE CROWNS PARK
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Dates
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Enumeration Date | 12/15/2015
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Last Update Date | 12/15/2015
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Provider Practice Location Address
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Address Line | 2323 MCDANIEL AVE
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City | EVANSTON
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State | IL
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Zip | 60201-2549
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Country | US
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Telephone | 847-328-8700
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Fax |
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Provider Business Mailing Address
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Address Line | 2323 MCDANIEL AVE
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City | EVANSTON
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State | IL
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Zip | 60201-2549
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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 | EXECUTIVE DIRECTOR
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Name | PHILIP HEMMER
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Credential |
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Telephone | 847-328-8700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 0012773
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 5102915
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 0012773
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License Number State | IL
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