Provider Demographics
NPI:1871039669
Name:MOUNT ST JOSEPH
Entity Type:Organization
Organization Name:MOUNT ST JOSEPH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT BENEFITS
Authorized Official - Prefix:
Authorized Official - First Name:RAE
Authorized Official - Middle Name:
Authorized Official - Last Name:EWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-438-5050
Mailing Address - Street 1:24955 N US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8919
Mailing Address - Country:US
Mailing Address - Phone:847-438-5050
Mailing Address - Fax:847-438-6313
Practice Address - Street 1:24955 N US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-8919
Practice Address - Country:US
Practice Address - Phone:847-438-5050
Practice Address - Fax:847-438-6313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005520315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities