Provider Demographics
NPI:1083433155
Name:HAVEN OF ST ELMO, LLC
Entity type:Organization
Organization Name:HAVEN OF ST ELMO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-905-3220
Mailing Address - Street 1:2201 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1519
Mailing Address - Country:US
Mailing Address - Phone:847-905-3222
Mailing Address - Fax:
Practice Address - Street 1:221 E CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT ELMO
Practice Address - State:IL
Practice Address - Zip Code:62458-1662
Practice Address - Country:US
Practice Address - Phone:618-829-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility