Provider Demographics
NPI:1417610163
Name:CRESTWOOD REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:CRESTWOOD REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, ECC
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNZIATO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:847-905-3000
Mailing Address - Street 1:2201 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1519
Mailing Address - Country:US
Mailing Address - Phone:847-905-3000
Mailing Address - Fax:
Practice Address - Street 1:14255 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-2154
Practice Address - Country:US
Practice Address - Phone:708-371-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6002265Medicaid