Provider Demographics
NPI:1487821260
Name:VICTORY CENTRE OF RIVER WOODS
Entity Type:Organization
Organization Name:VICTORY CENTRE OF RIVER WOODS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-547-5800
Mailing Address - Street 1:1800 RIVERWOODS DR
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1639
Mailing Address - Country:US
Mailing Address - Phone:708-547-5800
Mailing Address - Fax:708-345-7458
Practice Address - Street 1:1800 RIVERWOODS DR
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1639
Practice Address - Country:US
Practice Address - Phone:708-547-5800
Practice Address - Fax:708-345-7458
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAY SENIOR LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL364273297004310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364273297004Medicaid