Provider Demographics
NPI:1083759476
Name:ROSE GARDEN CARE CENTER INC.
Entity Type:Organization
Organization Name:ROSE GARDEN CARE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAN-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-905-4026
Mailing Address - Street 1:2201 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1519
Mailing Address - Country:US
Mailing Address - Phone:847-905-4026
Mailing Address - Fax:847-905-4040
Practice Address - Street 1:1629 E GARDNER LN
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-3613
Practice Address - Country:US
Practice Address - Phone:309-685-1545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0041780314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid