Provider Demographics
NPI:1063459626
Name:MANOR CARE OF KANKAKEE IL LLC
Entity Type:Organization
Organization Name:MANOR CARE OF KANKAKEE IL LLC
Other - Org Name:MANORCARE HEALTH SERVICES-KANKAKEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT - REIMBURSEMENTS
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAZARUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5541
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:ATTN: BARRY LAZARUS
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:419-252-5541
Mailing Address - Fax:419-252-5548
Practice Address - Street 1:900 W RIVER PL
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2932
Practice Address - Country:US
Practice Address - Phone:815-933-1711
Practice Address - Fax:815-933-2065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0400X
IL0027490314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145043Medicare Oscar/Certification