Provider Demographics
NPI:1922103589
Name:MARION REHABILITATION AND NURSING CENTER,LLC
Entity Type:Organization
Organization Name:MARION REHABILITATION AND NURSING CENTER,LLC
Other - Org Name:WILLOW OF THE FOUNTAIN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:C.F.O
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLIKSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-236-0000
Mailing Address - Street 1:8707 SKOKIE BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2269
Mailing Address - Country:US
Mailing Address - Phone:708-236-0000
Mailing Address - Fax:708-236-0001
Practice Address - Street 1:1301 E DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-3846
Practice Address - Country:US
Practice Address - Phone:618-997-1365
Practice Address - Fax:618-998-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040642314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6003230OtherFACILITY ID
IL=========001Medicaid
IL=========001Medicaid