Provider Demographics
NPI:1639814197
Name:WILLOUGHBY AL OPERATIONS, LLC
Entity Type:Organization
Organization Name:WILLOUGHBY AL OPERATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAXIM
Authorized Official - Middle Name:
Authorized Official - Last Name:STESEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-825-3336
Mailing Address - Street 1:8170 MCCORMICK BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2914
Mailing Address - Country:US
Mailing Address - Phone:773-825-3336
Mailing Address - Fax:
Practice Address - Street 1:35300 KAISER CT
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-6633
Practice Address - Country:US
Practice Address - Phone:440-269-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility