Provider Demographics
NPI:1568458693
Name:PRESENCE LIFE CONNECTIONS
Entity type:Organization
Organization Name:PRESENCE LIFE CONNECTIONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-7911
Mailing Address - Street 1:18927 HICKORY CREEK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8652
Mailing Address - Country:US
Mailing Address - Phone:708-478-7911
Mailing Address - Fax:708-478-5324
Practice Address - Street 1:20 BRIARCLIFF LN
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1665
Practice Address - Country:US
Practice Address - Phone:815-937-2022
Practice Address - Fax:815-936-3231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESENCE LIFE CONNECTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-23
Last Update Date:2016-03-01
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
145536Medicare UPIN