MEDICARE: CENTRAL BAPTIST HOME FOR THE AGED

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	310400000X	Assisted Living Facility	5100364	IL
2	314000000X	Skilled Nursing Facility	0007435	IL

General Provider Information

NPI Number	:	1841292083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL BAPTIST HOME FOR THE AGED

Provider Business Mailing Address
First Line	:	4747 N CANFIELD AVE
Second Line	:
City	:	NORRIDGE
State	:	IL
Zip	:	60706-4480
Country	:	US
Telephone Number	:	708-583-8555
Fax Number	:	708-583-8455

Provider Business Practice Location Address
First Line	:	4747 N CANFIELD AVE
Second Line	:
City	:	NORRIDGE
State	:	IL
Zip	:	60706-4480
Country	:	US
Telephone Number	:	708-583-8555
Fax Number	:	708-583-8455

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CHARLES NEWTON
Credential	:
Telephone Number	:	708-583-8500

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	10/03/2011

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