Provider Demographics
NPI:1104034289
Name:CAPITOL CARE CENTER, LLC
Entity Type:Organization
Organization Name:CAPITOL CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-329-4100
Mailing Address - Street 1:7444 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3214
Mailing Address - Country:US
Mailing Address - Phone:847-329-4100
Mailing Address - Fax:
Practice Address - Street 1:555 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4905
Practice Address - Country:US
Practice Address - Phone:847-329-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0045666314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145160Medicare ID - Type Unspecified