Provider Demographics
NPI:1992792527
Name:BRADLEY ROYALE, INC.
Entity type:Organization
Organization Name:BRADLEY ROYALE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:VARNAVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-933-1666
Mailing Address - Street 1:650 NORTH KINZIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1227
Mailing Address - Country:US
Mailing Address - Phone:815-933-1666
Mailing Address - Fax:815-933-9866
Practice Address - Street 1:650 NORTH KINZIE AVENUE
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1227
Practice Address - Country:US
Practice Address - Phone:815-933-1666
Practice Address - Fax:815-933-9866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0028712314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid
IL146112Medicare Oscar/Certification