MEDICARE: CLARK 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	:	1366995227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK SKILLED NURSING FACILITY LLC

Provider Business Mailing Address
First Line	:	3450 OAKTON ST
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-2951
Country	:	US
Telephone Number	:	847-679-9797
Fax Number	:	847-676-5348

Provider Business Practice Location Address
First Line	:	7433 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1619
Country	:	US
Telephone Number	:	773-338-8778
Fax Number	:	773-764-7449

Authorized Official
Title or Position	:	CEO
Name	:	YAIR ZUCKERMAN
Credential	:
Telephone Number	:	847-679-9797

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/27/2016

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