Provider Demographics
NPI:1629278346
Name:RENAISSANCE PARK SOUTH, LLC
Entity Type:Organization
Organization Name:RENAISSANCE PARK SOUTH, LLC
Other - Org Name:THE RENAISSANCE AT HALSTED, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-933-2600
Mailing Address - Street 1:7257 N. LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712
Mailing Address - Country:US
Mailing Address - Phone:847-933-2600
Mailing Address - Fax:773-928-9670
Practice Address - Street 1:10935 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3127
Practice Address - Country:US
Practice Address - Phone:773-928-2000
Practice Address - Fax:773-928-9670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145764Medicare Oscar/Certification