Provider Demographics
NPI:1255096640
Name:IVY GARDEN ADULT ACTIVITY CENTER LLC
Entity type:Organization
Organization Name:IVY GARDEN ADULT ACTIVITY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PLANNING
Authorized Official - Prefix:
Authorized Official - First Name:YMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-203-9988
Mailing Address - Street 1:2929 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-5803
Mailing Address - Country:US
Mailing Address - Phone:312-929-4577
Mailing Address - Fax:312-763-6158
Practice Address - Street 1:2929 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5803
Practice Address - Country:US
Practice Address - Phone:312-929-4577
Practice Address - Fax:312-763-6158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day CareGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILADS2212020OtherIDOA ADS