Provider Demographics
NPI:1336504117
Name:LAKE FOREST PLACE, LLC
Entity Type:Organization
Organization Name:LAKE FOREST PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVRILKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-979-3904
Mailing Address - Street 1:1100 PEMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-4228
Mailing Address - Country:US
Mailing Address - Phone:847-437-6700
Mailing Address - Fax:847-316-8723
Practice Address - Street 1:1100 PEMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-4228
Practice Address - Country:US
Practice Address - Phone:847-604-6700
Practice Address - Fax:847-979-3969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-22
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility