Provider Demographics
NPI:1982900445
Name:COVENANT HOME OF CHICAGO
Entity Type:Organization
Organization Name:COVENANT HOME OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:773-878-2294
Mailing Address - Street 1:2720 WEST FOSTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3510
Mailing Address - Country:US
Mailing Address - Phone:773-506-6900
Mailing Address - Fax:773-878-4530
Practice Address - Street 1:2720 WEST FOSTER AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3510
Practice Address - Country:US
Practice Address - Phone:773-506-6900
Practice Address - Fax:773-878-4530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT RETIREMENT COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility