MEDICARE: BLC-KENWOOD OF LAKE VIEW, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1063101178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLC-KENWOOD OF LAKE VIEW, LLC

Provider Business Mailing Address
First Line	:	6737 W WASHINGTON ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53214-5647
Country	:	US
Telephone Number	:	414-918-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3121 N SHERIDAN RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4945
Country	:	US
Telephone Number	:	773-404-9800
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	JOANNE LESKOWICZ
Credential	:
Telephone Number	:	414-918-5000

Provider Enumeration Date	:	05/04/2023
Last Update Date	:	05/04/2023

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