Provider Demographics
NPI:1184626434
Name:PROVIDENCE OPERATIONS, LLC
Entity type:Organization
Organization Name:PROVIDENCE OPERATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZANDSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-342-8137
Mailing Address - Street 1:18601 NORTH CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477
Mailing Address - Country:US
Mailing Address - Phone:708-342-8100
Mailing Address - Fax:708-342-8006
Practice Address - Street 1:3450 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1141
Practice Address - Country:US
Practice Address - Phone:630-969-2900
Practice Address - Fax:630-969-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0028605314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362382853003Medicaid
IL362382853003Medicaid