Provider Demographics
NPI:1881681245
Name:BLOOMINGDALE PAVILION, LLC
Entity Type:Organization
Organization Name:BLOOMINGDALE PAVILION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDS/CARE PLAN COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:630-894-7400
Mailing Address - Street 1:311 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1979
Mailing Address - Country:US
Mailing Address - Phone:630-894-7400
Mailing Address - Fax:630-894-8528
Practice Address - Street 1:311 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1979
Practice Address - Country:US
Practice Address - Phone:630-894-7400
Practice Address - Fax:630-894-8528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL44347314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid