Provider Demographics
NPI:1144461336
Name:GROVE OF LAGRANGE PARK LLC
Entity type:Organization
Organization Name:GROVE OF LAGRANGE PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJCHENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-679-9797
Mailing Address - Street 1:701 N LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1520
Mailing Address - Country:US
Mailing Address - Phone:708-354-7300
Mailing Address - Fax:708-354-8928
Practice Address - Street 1:701 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1520
Practice Address - Country:US
Practice Address - Phone:708-354-7300
Practice Address - Fax:708-354-8928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145307Medicare Oscar/Certification