Provider Demographics
NPI:1568461820
Name:REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Entity Type:Organization
Organization Name:REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Other - Org Name:PROVIDENCE AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZANDSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-342-8100
Mailing Address - Street 1:18601 N CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6397
Mailing Address - Country:US
Mailing Address - Phone:800-509-2800
Mailing Address - Fax:708-877-4818
Practice Address - Street 1:18601 N CREEK DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6397
Practice Address - Country:US
Practice Address - Phone:708-331-2005
Practice Address - Fax:708-877-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010138251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
147559OtherMEDICARE
IL50070OtherBC/BS PREFERRED PROVIDER
IL1010138OtherIL DEPT. OF PUBLIC HEALT
IL50070OtherBC/BS PREFERRED PROVIDER