Provider Demographics
NPI:1992833446
Name:PLUM GROVE OF PALATINE
Entity Type:Organization
Organization Name:PLUM GROVE OF PALATINE
Other - Org Name:THE PLUM GROVE OF PALATINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-677-9823
Mailing Address - Street 1:24 S PLUM GROVE RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-6243
Mailing Address - Country:US
Mailing Address - Phone:847-358-0311
Mailing Address - Fax:847-358-8875
Practice Address - Street 1:24 S PLUM GROVE RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-6243
Practice Address - Country:US
Practice Address - Phone:847-358-0311
Practice Address - Fax:847-358-8875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL48199314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203590254001Medicaid
ILT=========OtherBCBS OF IL INS
IL203590254001Medicaid