Provider Demographics
NPI:1902003221
Name:FAIRVIEW CARE CENTER OF LAGRANGE, LLC
Entity Type:Organization
Organization Name:FAIRVIEW CARE CENTER OF LAGRANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YOSEF
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYSTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-509-0027
Mailing Address - Street 1:3553 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3553 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3200
Practice Address - Country:US
Practice Address - Phone:773-509-0027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2020-08-22
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=========Medicaid
IL=========Medicaid