Provider Demographics
NPI:1013978675
Name:PRAIRIE VIEW CARE CENTER OF CHARLESTON, INC.
Entity Type:Organization
Organization Name:PRAIRIE VIEW CARE CENTER OF CHARLESTON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-674-4700
Mailing Address - Street 1:3856 OAKTON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3454
Mailing Address - Country:US
Mailing Address - Phone:847-674-4700
Mailing Address - Fax:847-674-4733
Practice Address - Street 1:716 18TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2382
Practice Address - Country:US
Practice Address - Phone:217-345-7054
Practice Address - Fax:317-348-1264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040311314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========801Medicaid
IL145636Medicare ID - Type Unspecified