Provider Demographics
NPI:1891011615
Name:GROVE OF EVANSTON LLC
Entity Type:Organization
Organization Name:GROVE OF EVANSTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-679-9797
Mailing Address - Street 1:500 ASBURY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2724
Mailing Address - Country:US
Mailing Address - Phone:847-316-3320
Mailing Address - Fax:847-316-3337
Practice Address - Street 1:500 ASBURY AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2724
Practice Address - Country:US
Practice Address - Phone:847-316-3320
Practice Address - Fax:847-316-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid