Provider Demographics
NPI:1124020474
Name:REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Entity Type:Organization
Organization Name:REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Other - Org Name:PROVIDENCE HEALTHCARE AND REHABILITATION CENTER SOUTH HOLLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONAL SYSTEMS
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-342-8179
Mailing Address - Street 1:16300 WAUSAU AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2158
Mailing Address - Country:US
Mailing Address - Phone:708-596-5500
Mailing Address - Fax:708-596-5527
Practice Address - Street 1:16300 WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2158
Practice Address - Country:US
Practice Address - Phone:708-596-5500
Practice Address - Fax:708-596-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0023242314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0594500001Medicare NSC
IL145671Medicare ID - Type Unspecified