Provider Demographics
NPI:1669626693
Name:BM OF CHICAGO RIDGE LLC
Entity Type:Organization
Organization Name:BM OF CHICAGO RIDGE LLC
Other - Org Name:CHICAGO RIDGE NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBOWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-679-7484
Mailing Address - Street 1:6500 N HAMLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3904
Mailing Address - Country:US
Mailing Address - Phone:847-679-7484
Mailing Address - Fax:
Practice Address - Street 1:10602 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1429
Practice Address - Country:US
Practice Address - Phone:708-448-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL314000000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========801Medicaid