Provider Demographics
NPI:1487841649
Name:VICTORY CENTRE OF PARK FOREST LLC
Entity Type:Organization
Organization Name:VICTORY CENTRE OF PARK FOREST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:E
Authorized Official - Last Name:FINIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-837-0704
Mailing Address - Street 1:333 W. WACKER DRIVE
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1202
Mailing Address - Country:US
Mailing Address - Phone:312-837-0701
Mailing Address - Fax:312-837-0728
Practice Address - Street 1:101 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2375
Practice Address - Country:US
Practice Address - Phone:708-283-2921
Practice Address - Fax:708-283-8364
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSL HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-01
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364270870001Medicaid