Provider Demographics
NPI:1780661165
Name:WILLOW CREST NURSING PAVILLION, LTD.
Entity Type:Organization
Organization Name:WILLOW CREST NURSING PAVILLION, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-679-8219
Mailing Address - Street 1:515 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1253
Mailing Address - Country:US
Mailing Address - Phone:815-786-8426
Mailing Address - Fax:815-786-1621
Practice Address - Street 1:515 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1253
Practice Address - Country:US
Practice Address - Phone:815-786-8426
Practice Address - Fax:815-786-1621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0036533314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
145712Medicare Oscar/Certification