Provider Demographics
NPI:1518238500
Name:BT BOURBONNAIS CARE, LLC
Entity Type:Organization
Organization Name:BT BOURBONNAIS CARE, LLC
Other - Org Name:BOURBONNAIS TERRACE N.H
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-501-0996
Mailing Address - Street 1:1S443 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3989
Mailing Address - Country:US
Mailing Address - Phone:847-767-5763
Mailing Address - Fax:
Practice Address - Street 1:133 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1349
Practice Address - Country:US
Practice Address - Phone:815-937-4790
Practice Address - Fax:815-937-0432
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JLM FINANCIAL HEALTHCARE, LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-23
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0051631Medicaid