Provider Demographics
NPI:1407855562
Name:REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Entity Type:Organization
Organization Name:REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Other - Org Name:PROVIDENCE HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERGENUGTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-342-8141
Mailing Address - Street 1:18601 N CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6397
Mailing Address - Country:US
Mailing Address - Phone:708-342-8100
Mailing Address - Fax:708-342-8006
Practice Address - Street 1:18601 N CREEK DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6397
Practice Address - Country:US
Practice Address - Phone:708-331-0400
Practice Address - Fax:708-877-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2002251251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2002251OtherHOSPICE LICENSE NUMBER
IL=========005Medicaid
IL2002251OtherHOSPICE LICENSE NUMBER
IL2002251OtherHOSPICE LICENSE NUMBER