Provider Demographics
NPI:1972264349
Name:GRAND VICTORIAN OF SYCAMORE
Entity type:Organization
Organization Name:GRAND VICTORIAN OF SYCAMORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RISK MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BECHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-837-0710
Mailing Address - Street 1:222 S RIVERSIDE PLZ FL 20
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-5808
Mailing Address - Country:US
Mailing Address - Phone:312-837-0701
Mailing Address - Fax:
Practice Address - Street 1:1440 SOMONAUK ST
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-2916
Practice Address - Country:US
Practice Address - Phone:815-895-1900
Practice Address - Fax:815-739-2253
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELL PATH TENANT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5107948OtherIDPH ASSISTED LIVING LICENSE