MEDICARE: CLEAR LAKE IA SKILLED NURSING FACILITY, 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1114792801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR LAKE IA SKILLED NURSING FACILITY, LLC

Provider Business Mailing Address
First Line	:	400 US HIGHWAY 18 W
Second Line	:
City	:	CLEAR LAKE
State	:	IA
Zip	:	50428-1108
Country	:	US
Telephone Number	:	641-357-5244
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 US HIGHWAY 18 W
Second Line	:
City	:	CLEAR LAKE
State	:	IA
Zip	:	50428-1108
Country	:	US
Telephone Number	:	641-357-5244
Fax Number	:

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	CHAIM RAJCHENBACH
Credential	:
Telephone Number	:	847-745-7000

Provider Enumeration Date	:	11/22/2023
Last Update Date	:	11/22/2023

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