Provider Demographics
NPI:1821212739
Name:FOX RIVER PAVILION LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:FOX RIVER PAVILION LIMITED PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:T
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-897-8714
Mailing Address - Street 1:400 E NEW YORK ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-3425
Mailing Address - Country:US
Mailing Address - Phone:630-897-8714
Mailing Address - Fax:630-897-2312
Practice Address - Street 1:400 E NEW YORK ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-3425
Practice Address - Country:US
Practice Address - Phone:630-897-8714
Practice Address - Fax:630-897-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038877314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========050501Medicaid
IL145894Medicare ID - Type Unspecified