Provider Demographics
NPI:1437286309
Name:PAVILION OF WAUKEGAN, II, INC.
Entity Type:Organization
Organization Name:PAVILION OF WAUKEGAN, II, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MASONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-997-1750
Mailing Address - Street 1:6350 N AVERS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1029
Mailing Address - Country:US
Mailing Address - Phone:847-997-1750
Mailing Address - Fax:773-478-0320
Practice Address - Street 1:2217 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5060
Practice Address - Country:US
Practice Address - Phone:847-997-1750
Practice Address - Fax:773-478-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0036467314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1167OtherBCBS OF IL INSURANCE
IL1167OtherBCBS OF IL INSURANCE
IL1167OtherBCBS OF IL INSURANCE