Provider Demographics
NPI:1023003092
Name:ELMHURST EXTENDED CARE CENTER
Entity Type:Organization
Organization Name:ELMHURST EXTENDED CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSARD
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:630-834-4337
Mailing Address - Street 1:200 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2013
Mailing Address - Country:US
Mailing Address - Phone:630-834-4337
Mailing Address - Fax:630-834-0480
Practice Address - Street 1:200 E LAKE ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2013
Practice Address - Country:US
Practice Address - Phone:630-834-4337
Practice Address - Fax:630-834-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1636066314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145111Medicare ID - Type Unspecified