Provider Demographics
NPI:1205488954
Name:LAUREATE KANKAKEE OPERATIONS LLC
Entity type:Organization
Organization Name:LAUREATE KANKAKEE OPERATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-426-8849
Mailing Address - Street 1:13024 BALNTYN CORP PL STE 425
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4420
Mailing Address - Country:US
Mailing Address - Phone:704-426-8849
Mailing Address - Fax:
Practice Address - Street 1:100 BELLE AIRE AVE
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2006
Practice Address - Country:US
Practice Address - Phone:815-939-0910
Practice Address - Fax:815-929-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness