Provider Demographics
NPI:1609843754
Name:WASHINGTON AND JANE SMITH COMMUNITY BEVERLY
Entity Type:Organization
Organization Name:WASHINGTON AND JANE SMITH COMMUNITY BEVERLY
Other - Org Name:SMITH VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MARNERIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-474-7350
Mailing Address - Street 1:2320 W 113TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4117
Mailing Address - Country:US
Mailing Address - Phone:773-474-7300
Mailing Address - Fax:773-474-7342
Practice Address - Street 1:11308 S OAKLEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4112
Practice Address - Country:US
Practice Address - Phone:773-474-7300
Practice Address - Fax:773-474-7342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0015032314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000015032Medicaid
IL145904Medicare ID - Type Unspecified