Provider Demographics
NPI:1710971288
Name:HICKORY NURSING PAVILION
Entity Type:Organization
Organization Name:HICKORY NURSING PAVILION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WENGROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-598-4040
Mailing Address - Street 1:3737 W ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-4029
Mailing Address - Country:US
Mailing Address - Phone:847-679-2121
Mailing Address - Fax:847-679-2122
Practice Address - Street 1:9246 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-2066
Practice Address - Country:US
Practice Address - Phone:708-598-4040
Practice Address - Fax:708-598-3796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0032029314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145866Medicare Oscar/Certification