MEDICARE: PROVIDENCE OPERATIONS, 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	0028605	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174525422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE OPERATIONS, LLC

Provider Business Mailing Address
First Line	:	18601 N CREEK DR
Second Line	:
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-6397
Country	:	US
Telephone Number	:	708-342-8100
Fax Number	:	708-342-8006

Provider Business Practice Location Address
First Line	:	13259 S CENTRAL AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-2601
Country	:	US
Telephone Number	:	708-597-1000
Fax Number	:	708-597-1000

Authorized Official
Title or Position	:	COMPLIANCE OFFICER
Name	:	MRS. JOHANNA R ZANDSTRA
Credential	:
Telephone Number	:	708-342-8137

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	09/23/2015

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Directions to “PROVIDENCE OPERATIONS, LLC ” Practice Location

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