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NPI Code Detail

MEDICARE: GAF/LAKE COOK TERRACE

MEDICARE: GAF/LAKE COOK TERRACE
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
1311Z00000XCustodial Care Facility

Other Identifiers

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

General Provider Information

NPI Number : 1659368264
Entity Type Code : Organization
Provider Name (Legal Business Name) : GAF/LAKE COOK TERRACE
Provider Business Mailing Address
First Line : 263 SKOKIE BLVD
Second Line :
City : NORTHBROOK
State : IL
Zip : 60062-1611
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 263 SKOKIE BLVD
Second Line :
City : NORTHBROOK
State : IL
Zip : 60062-1611
Country : US
Telephone Number : 847-564-0505
Fax Number :
Authorized Official
Title or Position : MDS COORDINATOR
Name : MELODY GOODMAN
Credential :
Telephone Number : 847-564-0505
Provider Enumeration Date : 09/29/2005
Last Update Date : 08/22/2020

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Directions to “GAF/LAKE COOK TERRACE ” Practice Location

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