Provider Demographics
NPI:1144794207
Name:PARADOX CHAMPAIGN OPERATOR LLC
Entity Type:Organization
Organization Name:PARADOX CHAMPAIGN OPERATOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER LLC
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-905-4000
Mailing Address - Street 1:309 E SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5405
Mailing Address - Country:US
Mailing Address - Phone:217-352-5135
Mailing Address - Fax:
Practice Address - Street 1:309 E SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-5405
Practice Address - Country:US
Practice Address - Phone:217-352-5135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0055467OtherIL DEPT OF PUBLIC HEALTH