Provider Demographics
NPI:1265443915
Name:ALPINE FIRESIDE HEALTH CENTER LTD
Entity Type:Organization
Organization Name:ALPINE FIRESIDE HEALTH CENTER LTD
Other - Org Name:APLINE FIRESIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:O
Authorized Official - Last Name:OKSNERAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-877-7408
Mailing Address - Street 1:3650 NORTH ALPINE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4806
Mailing Address - Country:US
Mailing Address - Phone:815-877-7408
Mailing Address - Fax:815-461-8800
Practice Address - Street 1:3650 NORTH ALPINE ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4806
Practice Address - Country:US
Practice Address - Phone:815-877-7408
Practice Address - Fax:815-461-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0018275310400000X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL146066Medicare Oscar/Certification