Provider Demographics
NPI:1720031156
Name:FOUNTAINS CRYSTAL LAKE SL LLC
Entity Type:Organization
Organization Name:FOUNTAINS CRYSTAL LAKE SL LLC
Other - Org Name:FOUNTAINS AT CRYSTAL LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRETA
Authorized Official - Middle Name:FRUHLING
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-797-4000
Mailing Address - Street 1:965 N BRIGHTON CIR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-2036
Mailing Address - Country:US
Mailing Address - Phone:815-455-8400
Mailing Address - Fax:815-477-6502
Practice Address - Street 1:1000 E BRIGHTON LN
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-2074
Practice Address - Country:US
Practice Address - Phone:815-455-8400
Practice Address - Fax:815-477-6502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0047217314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145612Medicare ID - Type Unspecified