Provider Demographics
NPI:1194902353
Name:BETH ANNE EXTENDED LIVING
Entity type:Organization
Organization Name:BETH ANNE EXTENDED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:773-473-7870
Mailing Address - Street 1:1143 N LAVERGNE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3117
Mailing Address - Country:US
Mailing Address - Phone:773-287-2711
Mailing Address - Fax:773-473-7871
Practice Address - Street 1:1143 N LAVERGNE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3117
Practice Address - Country:US
Practice Address - Phone:773-287-2711
Practice Address - Fax:773-473-7871
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHEL NEW LIFE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-29
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility