Provider Demographics
NPI:1972522134
Name:PINE ACRES REHAB & LIVING CTR
Entity type:Organization
Organization Name:PINE ACRES REHAB & LIVING CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WELDLER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:630-355-3300
Mailing Address - Street 1:1212 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4435
Mailing Address - Country:US
Mailing Address - Phone:815-758-8151
Mailing Address - Fax:815-758-8111
Practice Address - Street 1:1212 S 2ND ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4435
Practice Address - Country:US
Practice Address - Phone:815-758-8151
Practice Address - Fax:815-758-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0047720314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145261Medicare ID - Type Unspecified