Provider Demographics
NPI:1790374510
Name:HARBOR HOUSE OF WHEELING IV, LLC
Entity Type:Organization
Organization Name:HARBOR HOUSE OF WHEELING IV, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-440-2660
Mailing Address - Street 1:760 MCHENRY RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3861
Mailing Address - Country:US
Mailing Address - Phone:847-465-1100
Mailing Address - Fax:847-465-0146
Practice Address - Street 1:760 MCHENRY RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3861
Practice Address - Country:US
Practice Address - Phone:847-465-1100
Practice Address - Fax:847-465-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0055624OtherSTATE LICENSE