Provider Demographics
NPI:1639541931
Name:LAGRANGE SKILLED NURSING FACILITY LLC
Entity Type:Organization
Organization Name:LAGRANGE SKILLED NURSING FACILITY LLC
Other - Org Name:THE GROVE OF LAGRANGE PARK LIVING & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
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 1:701 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PK
Practice Address - State:IL
Practice Address - Zip Code:60526-1520
Practice Address - Country:US
Practice Address - Phone:708-354-7300
Practice Address - Fax:708-354-8928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
145307Medicare Oscar/Certification