Provider Demographics
NPI:1124173844
Name:EAST BANK CENTER LLC
Entity type:Organization
Organization Name:EAST BANK CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-633-6810
Mailing Address - Street 1:12040 RAYMOND CT
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-8069
Mailing Address - Country:US
Mailing Address - Phone:847-515-1505
Mailing Address - Fax:847-515-1503
Practice Address - Street 1:6131 PARK RIDGE RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4029
Practice Address - Country:US
Practice Address - Phone:815-633-6810
Practice Address - Fax:815-633-5095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0047209314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146069Medicare ID - Type UnspecifiedPROVIDER NUMBER