Provider Demographics
NPI:1619456670
Name:ELGIN SKILLED NURSING FACILITY LLC
Entity Type:Organization
Organization Name:ELGIN SKILLED NURSING FACILITY LLC
Other - Org Name:AVANTARA OF ELGIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:MENACHEM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHABAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-679-9797
Mailing Address - Street 1:3450 OAKTON ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2951
Mailing Address - Country:US
Mailing Address - Phone:847-679-9797
Mailing Address - Fax:847-679-1026
Practice Address - Street 1:1950 LARKIN AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5843
Practice Address - Country:US
Practice Address - Phone:847-742-7070
Practice Address - Fax:847-742-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid