Provider Demographics
NPI:1144422676
Name:SJV 1 WHEATON OPCO LLC
Entity type:Organization
Organization Name:SJV 1 WHEATON OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR REIMBURSEMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-854-0830
Mailing Address - Street 1:831 BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-8674
Mailing Address - Country:US
Mailing Address - Phone:630-681-1234
Mailing Address - Fax:
Practice Address - Street 1:831 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-8674
Practice Address - Country:US
Practice Address - Phone:630-681-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5101636310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility