Provider Demographics
NPI:1588652317
Name:ALDEN OF OLD TOWN WEST, INC.
Entity Type:Organization
Organization Name:ALDEN OF OLD TOWN WEST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHLOSSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-286-6622
Mailing Address - Street 1:4200 W PETERSON AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6074
Mailing Address - Country:US
Mailing Address - Phone:773-286-6622
Mailing Address - Fax:773-286-2150
Practice Address - Street 1:118 S BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1239
Practice Address - Country:US
Practice Address - Phone:630-671-1660
Practice Address - Fax:630-671-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0042077315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid