Provider Demographics
NPI:1194859892
Name:ABBOTT HOUSE, LLC
Entity Type:Organization
Organization Name:ABBOTT HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IVY
Authorized Official - Middle Name:K
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:847-432-6080
Mailing Address - Street 1:405 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2622
Mailing Address - Country:US
Mailing Address - Phone:847-432-6080
Mailing Address - Fax:847-432-7286
Practice Address - Street 1:405 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2622
Practice Address - Country:US
Practice Address - Phone:847-432-6080
Practice Address - Fax:847-432-7286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0023739310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0023739OtherPUBLIC HEALTH LICENSE NUM
IL=========0001Medicaid