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General NPI Number Information
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NPI Number | 1699746420
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Entity Type | Organization
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Legal Business Name | ST AGNES MANOR INC
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Dates
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Enumeration Date | 01/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1725 S WABASH AVE
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City | CHICAGO
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State | IL
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Zip | 60616-1219
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Country | US
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Telephone | 312-922-2777
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Fax | 312-939-1820
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Provider Business Mailing Address
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Address Line | 1541 N WELLS ST
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City | CHICAGO
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State | IL
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Zip | 60610-1307
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Country | US
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Telephone | 312-787-9400
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Fax | 312-787-9434
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MR. PETER J O'BRIEN
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Credential |
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Telephone | 312-787-9400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 0027870
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License Number State | IL
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