Provider Demographics
NPI:1598188237
Name:LONG GROVE PAC LLC
Entity Type:Organization
Organization Name:LONG GROVE PAC LLC
Other - Org Name:AVANTARA LONG GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:YAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUCKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-679-9797
Mailing Address - Street 1:7040 N RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2620
Mailing Address - Country:US
Mailing Address - Phone:847-679-9797
Mailing Address - Fax:847-676-5348
Practice Address - Street 1:1666 RFD
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-7368
Practice Address - Country:US
Practice Address - Phone:847-419-1111
Practice Address - Fax:847-419-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
145868Medicare Oscar/Certification