Provider Demographics
NPI:1689884629
Name:IMPERIAL OF HAZELCREST
Entity Type:Organization
Organization Name:IMPERIAL OF HAZELCREST
Other - Org Name:CAREPLUS MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAN-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-329-1555
Mailing Address - Street 1:8320 SKOKIE BLVD
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2545
Mailing Address - Country:US
Mailing Address - Phone:847-329-1555
Mailing Address - Fax:
Practice Address - Street 1:8320 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2545
Practice Address - Country:US
Practice Address - Phone:847-329-1555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00=========Medicaid