Provider Demographics
NPI:1891780946
Name:PROVENA SENIOR SERVICES
Entity type:Organization
Organization Name:PROVENA SENIOR SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR. PATIENT FINANCIAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-506-2351
Mailing Address - Street 1:19065 HICKORY CREEK PL
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8507
Mailing Address - Country:US
Mailing Address - Phone:708-478-7900
Mailing Address - Fax:708-478-5387
Practice Address - Street 1:1101 E STATE ST
Practice Address - Street 2:PROVENA GENEVA CARE CENTER
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2438
Practice Address - Country:US
Practice Address - Phone:630-232-7544
Practice Address - Fax:630-232-4409
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVENA SENIOR SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-14
Last Update Date:2022-07-21
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=========005Medicaid
IL=========OtherSTATE LICENSE NUMBER
IL=========OtherSTATE LICENSE NUMBER