Provider Demographics
NPI:1760470553
Name:ALDEN OF WATERFORD, L.L.C.
Entity Type:Organization
Organization Name:ALDEN OF WATERFORD, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHLOSSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-286-6622
Mailing Address - Street 1:4200 W PETERSON AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6074
Mailing Address - Country:US
Mailing Address - Phone:773-286-6622
Mailing Address - Fax:773-286-2150
Practice Address - Street 1:2021 RANDI DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4758
Practice Address - Country:US
Practice Address - Phone:630-851-7266
Practice Address - Fax:630-851-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0042036314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50214OtherBLUE CROSS
IL=========001Medicaid
IL=========001Medicaid