Provider Demographics
NPI:1780673954
Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Entity Type:Organization
Organization Name:WISCONSIN ILLINOIS SENIOR HOUSING INC.
Other - Org Name:FAIR OAKS HEALTH CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICARE PROGRAM MONITOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-980-0611
Mailing Address - Street 1:471 W TERRA COTTA AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3434
Mailing Address - Country:US
Mailing Address - Phone:815-455-0550
Mailing Address - Fax:815-356-3846
Practice Address - Street 1:471 W TERRA COTTA AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3434
Practice Address - Country:US
Practice Address - Phone:815-455-0550
Practice Address - Fax:815-356-3846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040915314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6002976Medicaid
IL6002976Medicaid
IL6002976Medicaid