Provider Demographics
NPI:1972206332
Name:BRIA OF ELMWOOD PARK LLC
Entity Type:Organization
Organization Name:BRIA OF ELMWOOD PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-933-9200
Mailing Address - Street 1:5151 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1123
Mailing Address - Country:US
Mailing Address - Phone:847-933-9200
Mailing Address - Fax:847-933-9765
Practice Address - Street 1:7733 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-1820
Practice Address - Country:US
Practice Address - Phone:708-452-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility