Provider Demographics
NPI:1073345641
Name:BEACON PACE ILLINOIS LLC
Entity type:Organization
Organization Name:BEACON PACE ILLINOIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CZERMAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-608-1975
Mailing Address - Street 1:106 W MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-3551
Mailing Address - Country:US
Mailing Address - Phone:732-806-3205
Mailing Address - Fax:
Practice Address - Street 1:1700 167TH ST
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5458
Practice Address - Country:US
Practice Address - Phone:855-801-2653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-14
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization