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General NPI Number Information
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NPI Number | 1467761312
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Entity Type | Organization
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Legal Business Name | PARK LAWN CENTER
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Dates
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Enumeration Date | 09/27/2010
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Last Update Date | 09/27/2010
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Provider Practice Location Address
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Address Line | 10833 LAPORTE AVE
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City | OAK LAWN
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State | IL
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Zip | 60453-5412
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Country | US
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Telephone | 708-425-3344
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Fax | 708-425-3530
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Provider Business Mailing Address
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Address Line | 5831 W 115TH ST
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City | ALSIP
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State | IL
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Zip | 60803-5150
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Country | US
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Telephone | 708-396-1117
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Fax | 708-396-1186
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JAMES R. WEISE
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Credential |
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Telephone | 708-425-3344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 0027078
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License Number State | IL
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