Provider Demographics
NPI:1376960039
Name:KING-BRUWAERT HOUSE
Entity Type:Organization
Organization Name:KING-BRUWAERT HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-230-9502
Mailing Address - Street 1:6101 S COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8132
Mailing Address - Country:US
Mailing Address - Phone:630-323-2250
Mailing Address - Fax:630-655-8179
Practice Address - Street 1:6101 S COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-8132
Practice Address - Country:US
Practice Address - Phone:630-323-2250
Practice Address - Fax:630-655-8179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002584314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility