Provider Demographics
NPI:1487803938
Name:CORTLAND MANOR LLC
Entity type:Organization
Organization Name:CORTLAND MANOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER-CORTLAND MANOR LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:D.ARCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-655-7492
Mailing Address - Street 1:1900 N. KARLOV AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639
Mailing Address - Country:US
Mailing Address - Phone:773-252-9941
Mailing Address - Fax:773-252-9946
Practice Address - Street 1:1900 N. KARLOV AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639
Practice Address - Country:US
Practice Address - Phone:773-252-9941
Practice Address - Fax:773-252-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-60639-01Medicaid