Provider Demographics
NPI:1285943134
Name:PARK LAWN HOME
Entity type:Organization
Organization Name:PARK LAWN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-425-3344
Mailing Address - Street 1:12615 S KOSTNER AVE
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-2625
Mailing Address - Country:US
Mailing Address - Phone:708-385-1982
Mailing Address - Fax:708-385-8145
Practice Address - Street 1:10833 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5412
Practice Address - Country:US
Practice Address - Phone:708-425-3344
Practice Address - Fax:708-425-3530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK LAWN SCHOOL & ACTIVITY CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0035527315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0035527Medicaid