Provider Demographics
NPI:1285796714
Name:CARLTON AT THE LAKE INC
Entity type:Organization
Organization Name:CARLTON AT THE LAKE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:SLESUR
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:847-763-2550
Mailing Address - Street 1:725 W MONTROSE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:773-929-1700
Mailing Address - Fax:773-929-3068
Practice Address - Street 1:725 W MONTROSE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-929-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
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
145679Medicare ID - Type Unspecified