=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679633192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLC - PARK PLACE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 N WABASH AVE SUITE 1400
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-977-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S PARK RD
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99212-0593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-922-7224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARK J. SCHULTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-977-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | BH 1759
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------