Provider Demographics
NPI:1093704165
Name:WOODBINE NURSING HOME LLC
Entity Type:Organization
Organization Name:WOODBINE NURSING HOME LLC
Other - Org Name:THE WOODBINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BARAK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-202-0000
Mailing Address - Street 1:4055 W PETERSON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6182
Mailing Address - Country:US
Mailing Address - Phone:773-202-0000
Mailing Address - Fax:773-267-0111
Practice Address - Street 1:6909 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1008
Practice Address - Country:US
Practice Address - Phone:708-386-1112
Practice Address - Fax:708-524-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0044446314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid