Provider Demographics
NPI:1851396238
Name:FAIRVIEW NURSING PLAZA, INC.
Entity Type:Organization
Organization Name:FAIRVIEW NURSING PLAZA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:847-674-5200
Mailing Address - Street 1:4100 W PRATT AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3517
Mailing Address - Country:US
Mailing Address - Phone:847-674-5200
Mailing Address - Fax:847-674-5267
Practice Address - Street 1:321 ARNOLD AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2315
Practice Address - Country:US
Practice Address - Phone:815-397-5531
Practice Address - Fax:815-397-7629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0037655314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6047950001Medicare NSC
IL14-5937Medicare ID - Type Unspecified