Provider Demographics
NPI:1053803031
Name:LAKE TERRACE NURSING AND REHAB LLC
Entity type:Organization
Organization Name:LAKE TERRACE NURSING AND REHAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:STESEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-825-3336
Mailing Address - Street 1:8170 MCCORMICK BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2914
Mailing Address - Country:US
Mailing Address - Phone:773-825-3336
Mailing Address - Fax:847-423-6991
Practice Address - Street 1:2115 E WOODSTOCK PL
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1342
Practice Address - Country:US
Practice Address - Phone:414-271-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3150314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility