=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508029919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NILES NURSING & REHABILITATION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2008
-----------------------------------------------------
Last Update Date | 07/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9777 N GREENWOOD AVE
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-967-7000
-----------------------------------------------------
Fax | 847-967-5054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9777 N GREENWOOD AVE
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-967-7000
-----------------------------------------------------
Fax | 847-967-5054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. MICHAEL BLISKO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-791-7859
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------