Provider Demographics
NPI:1831175041
Name:ASPEN RIDGE CARE CENTRE LLC
Entity type:Organization
Organization Name:ASPEN RIDGE CARE CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-583-0100
Mailing Address - Street 1:2530 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3249
Mailing Address - Country:US
Mailing Address - Phone:217-875-0920
Mailing Address - Fax:217-876-9351
Practice Address - Street 1:2530 N MONROE ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3249
Practice Address - Country:US
Practice Address - Phone:217-875-0920
Practice Address - Fax:217-876-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL42481314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6006282OtherIDPA FACILITY NUMBER
IL42481OtherIDPH LICENSE NUMBER
IL6006282OtherIDPA FACILITY NUMBER
IL=========001Medicaid
IL146003Medicare Oscar/Certification