Provider Demographics
NPI:1902994650
Name:SACRED HEART HOME
Entity Type:Organization
Organization Name:SACRED HEART HOME
Other - Org Name:MADO HEALTHCARE - DOUGLAS PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-787-9400
Mailing Address - Street 1:405 N WABASH AVE STE P2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3541
Mailing Address - Country:US
Mailing Address - Phone:312-787-9400
Mailing Address - Fax:312-787-9434
Practice Address - Street 1:1550 S ALBANY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2212
Practice Address - Country:US
Practice Address - Phone:773-277-6868
Practice Address - Fax:773-277-5014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0013334310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid