Provider Demographics
NPI:1366639833
Name:SHABBONA SUPPORTIVE LIVING
Entity Type:Organization
Organization Name:SHABBONA SUPPORTIVE LIVING
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:J
Authorized Official - Last Name:NICOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-824-8480
Mailing Address - Street 1:407 W COMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:SHABBONA
Mailing Address - State:IL
Mailing Address - Zip Code:60550-9501
Mailing Address - Country:US
Mailing Address - Phone:815-824-8480
Mailing Address - Fax:815-824-2412
Practice Address - Street 1:407 W COMANCHE AVE
Practice Address - Street 2:
Practice Address - City:SHABBONA
Practice Address - State:IL
Practice Address - Zip Code:60550-9501
Practice Address - Country:US
Practice Address - Phone:815-824-8480
Practice Address - Fax:815-824-2412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204590974001Medicaid