Provider Demographics
NPI:1396024964
Name:GROVE AT THE LAKE LIVING AND REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:GROVE AT THE LAKE LIVING AND REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REUVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVITIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-676-5307
Mailing Address - Street 1:7040 N RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2620
Mailing Address - Country:US
Mailing Address - Phone:847-679-9797
Mailing Address - Fax:
Practice Address - Street 1:2534 ELIM AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2661
Practice Address - Country:US
Practice Address - Phone:847-746-8435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2019775314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid