Provider Demographics
NPI:1881671741
Name:LUTHERAN HOME FOR AGED DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:LUTHERAN HOME FOR AGED DEVELOPMENT CORPORATION
Other - Org Name:PRAIRIEVIEW LUTHERAN HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-269-2970
Mailing Address - Street 1:403 NORTH FOURTH ST.
Mailing Address - Street 2:
Mailing Address - City:DANFORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60930
Mailing Address - Country:US
Mailing Address - Phone:815-269-2970
Mailing Address - Fax:815-269-2930
Practice Address - Street 1:403 NORTH FOURTH ST.
Practice Address - Street 2:
Practice Address - City:DANFORTH
Practice Address - State:IL
Practice Address - Zip Code:60930
Practice Address - Country:US
Practice Address - Phone:815-269-2970
Practice Address - Fax:815-269-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0018044314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145953Medicare Oscar/Certification
IL=========OtherLONG TERM CARE
IL=========001Medicaid