Provider Demographics
NPI:1649220906
Name:CC LAKE INC
Entity Type:Organization
Organization Name:CC LAKE INC
Other - Org Name:VI AT THE GLEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP & GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:COPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-803-8555
Mailing Address - Street 1:71 S WACKER DR
Mailing Address - Street 2:SUITE 900
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-4637
Mailing Address - Country:US
Mailing Address - Phone:312-803-8520
Mailing Address - Fax:
Practice Address - Street 1:2401 INDIGO LN
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1299
Practice Address - Country:US
Practice Address - Phone:847-904-4710
Practice Address - Fax:847-904-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1705143314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146107Medicare PIN
IL14-6107Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER