=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679578041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERATIONS AT COLUMBUS PARK,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2005
-----------------------------------------------------
Last Update Date | 08/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 S AUSTIN BLVD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60644-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-287-5959
-----------------------------------------------------
Fax | 773-287-7909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6840 N LINCOLN AVE
-----------------------------------------------------
City | LINCOLNWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60712-2628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-675-7979
-----------------------------------------------------
Fax | 847-674-5267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. THOMAS WINTER
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 847-675-7979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 0037960
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------