=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306397427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHARON HEALTHCARE WILLOWS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2016
-----------------------------------------------------
Last Update Date | 10/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 465 CENTRAL AVE
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-3045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-441-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3520 N ROCHELLE LN
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61604-1037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF FINANCE
-----------------------------------------------------
Name | ELISA J. SHLOFROCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-441-8200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 0032797
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------