Provider Demographics
NPI:1497723464
Name:WYNDEMERE LLC
Entity Type:Organization
Organization Name:WYNDEMERE LLC
Other - Org Name:WYNDEMERE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUXO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-875-4500
Mailing Address - Street 1:2180 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-4580
Mailing Address - Country:US
Mailing Address - Phone:630-681-4200
Mailing Address - Fax:
Practice Address - Street 1:2180 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4580
Practice Address - Country:US
Practice Address - Phone:630-681-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0050674310400000X
IL41426314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363436685002Medicaid
IL363436685002Medicaid