Provider Demographics
NPI:1003071895
Name:BRENTWOOD HEALTHCARE AND REHABILITATION CENTRE, LLC
Entity Type:Organization
Organization Name:BRENTWOOD HEALTHCARE AND REHABILITATION CENTRE, LLC
Other - Org Name:BRENTWOOD NORTH NURSING & REHAB CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-674-5454
Mailing Address - Street 1:3705 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3540
Mailing Address - Country:US
Mailing Address - Phone:847-947-9000
Mailing Address - Fax:847-947-9005
Practice Address - Street 1:3705 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-3540
Practice Address - Country:US
Practice Address - Phone:847-947-9000
Practice Address - Fax:847-947-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
14-5304Medicare PIN