MEDICARE: PLAZA TERRACE NURSING HOME

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	1566662	IL

General Provider Information

NPI Number	:	1255305165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLAZA TERRACE NURSING HOME

Provider Business Mailing Address
First Line	:	3249 W 147TH STREET
Second Line	:
City	:	MIDLOTHIAN
State	:	IL
Zip	:	60445
Country	:	US
Telephone Number	:	708-389-3141
Fax Number	:	708-396-1626

Provider Business Practice Location Address
First Line	:	3249 W 147TH STREET
Second Line	:
City	:	MIDLOTHIAN
State	:	IL
Zip	:	60445
Country	:	US
Telephone Number	:	708-389-3141
Fax Number	:	708-396-1626

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LATONYA ELOISE DAVIS
Credential	:	RN
Telephone Number	:	708-389-3141

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	08/22/2020

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