Provider Demographics
NPI:1093706277
Name:AMBASSADOR NURSING CENTER
Entity Type:Organization
Organization Name:AMBASSADOR NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-674-7600
Mailing Address - Street 1:4900 N BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5146
Mailing Address - Country:US
Mailing Address - Phone:773-583-7130
Mailing Address - Fax:773-583-3929
Practice Address - Street 1:4900 N BERNARD ST
Practice Address - Street 2:ATTN: LEONARD WEISS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5146
Practice Address - Country:US
Practice Address - Phone:773-583-7130
Practice Address - Fax:773-583-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004077314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid