Provider Demographics
NPI:1851795686
Name:PH PROVIDENCE, LLC
Entity Type:Organization
Organization Name:PH PROVIDENCE, LLC
Other - Org Name:PROVIDENCE PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-329-4100
Mailing Address - Street 1:7444 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3214
Mailing Address - Country:US
Mailing Address - Phone:847-329-4100
Mailing Address - Fax:
Practice Address - Street 1:401 E 20TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41014-1583
Practice Address - Country:US
Practice Address - Phone:845-732-9410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility