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General NPI Number Information
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NPI Number | 1821355561
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Entity Type | Organization
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Legal Business Name | LTC PRACTITIONERS OF ILLINOIS
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Dates
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Enumeration Date | 04/19/2012
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Last Update Date | 04/19/2012
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Provider Practice Location Address
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Address Line | 3915 N. KENNETH AVE.
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City | CHICAGO
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State | IL
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Zip | 60641-2816
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Country | US
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Telephone | 773-401-4412
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Fax | 312-492-6269
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Provider Business Mailing Address
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Address Line | 3915 N KENNETH AVE
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City | CHICAGO
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State | IL
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Zip | 60641-2816
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Country | US
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Telephone | 773-401-4412
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Fax | 312-492-6269
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | SUE E. WILSON
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Credential | APN
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Telephone | 773-401-4412
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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 | 209009340
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License Number State | IL
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