Provider Demographics
NPI:1518154871
Name:RENAISSANCE CENTER
Entity Type:Organization
Organization Name:RENAISSANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-768-5114
Mailing Address - Street 1:2800 WEST FULTON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:773-722-2900
Mailing Address - Fax:773-722-7662
Practice Address - Street 1:2800 WEST FULTON
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:773-722-2900
Practice Address - Fax:773-722-7662
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAY SENIOR LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========01Medicaid