Provider Demographics
NPI:1659368264
Name:GAF/LAKE COOK TERRACE
Entity Type:Organization
Organization Name:GAF/LAKE COOK TERRACE
Other - Org Name:LAKE COOK HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MDS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-564-0505
Mailing Address - Street 1:263 SKOKIE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:263 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1611
Practice Address - Country:US
Practice Address - Phone:847-564-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3639624779001Medicaid
IL145809Medicare ID - Type Unspecified