Provider Demographics
NPI:1174541809
Name:CHICAGOLAND CHRISTIAN VILLAGE, INC.
Entity type:Organization
Organization Name:CHICAGOLAND CHRISTIAN VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-732-5175
Mailing Address - Street 1:6685 E 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7808
Mailing Address - Country:US
Mailing Address - Phone:219-662-0642
Mailing Address - Fax:219-663-4260
Practice Address - Street 1:6685 E 117TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7808
Practice Address - Country:US
Practice Address - Phone:219-662-0642
Practice Address - Fax:219-663-4260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000272904OtherANTHEM BC/BS PROVIDER NUM
IN155637Medicare Oscar/Certification