NPIMap

Organization Active NPI

Fullerton Skilled Nursing Facility LLC

Doing business as Avantara Lincoln Park

  • Skilled Nursing Facility
  • Chicago, IL
National Provider Identifier
1386332906
Registry record updated May 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
FULLERTON SKILLED NURSING FACILITY LLC
Doing business as
Avantara Lincoln Park
Practice address
1366 W Fullerton Ave
Chicago, IL 60614-2129
Phone
(773) 248-9300
Fax
(773) 935-0036
NPI assigned
May 1, 2023
Last updated
May 1, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 1, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Menachem Shabat
Title
Coo
Phone
(773) 248-9300

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NU Primary

Addresses

Primary practice location

1366 W Fullerton Ave
Chicago, IL 60614-2129

Mailing address

3450 Oakton St
Skokie, IL 60076-2951
Phone (847) 679-9797

Other names 1

  • Avantara Lincoln Park Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20231205000802 IL Part A Provider - Skilled Nursing Facility 5890143655 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386332906. Details of each certification follow.

Skilled nursing facility certification: CCN 145510

Legal name
FULLERTON SKILLED NURSING FACILITY LLC
Doing business as
AVANTARA LINCOLN PARK
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Sep 25, 1984
Last certification
Jun 7, 2024
Beds
248
Ownership / control type
Corporation
Multi-facility organization
Legacy Healthcare
Most recent change of ownership
Oct 6, 2023
Organization structure
LLCProprietary
Enrollment address
1366 W Fullerton Ave
Chicago, IL 60614-2129
Nursing home name
AVANTARA LINCOLN PARK
Affiliated entity
LEGACY HEALTHCARE

Care Compare: Nursing home

Medicare Care Compare
Listed as
Avantara Lincoln ParkCCN 145510 · All quality measures
Overall star rating
2 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Sep 25, 1984
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
248223.2 residents per day on average
Chain
Legacy Healthcare89 facilities in the chain
Abuse citation
Cited for abuse (Care Compare abuse icon)
Penalties (3 years)
4Fines totaling $202,448

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Avantara Lincoln Park3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Individual Indirect Ownership Interest Oct 6, 2023 2.6%
Louise Dihiansan Individual Operational/Managerial Control Oct 6, 2023
Adp of the SNF Oct 6, 2023
Fullerton SNF Property Holdings LLC Organization, Skokie, IL LLC 5% Or Greater Security Interest Oct 6, 2023 100%
Adp of the SNF Oct 6, 2023
Menachem Shabat Individual Operational/Managerial Control Oct 6, 2023
Managing Control - Governing BodyManager of the Manager Oct 6, 2023
Adp of the SNF Oct 6, 2023
Roth & Co, LLP Organization, Brooklyn, NY Consulting firm Adp of the SNF Oct 6, 2023
Rajesh Iyengar Individual Operational/Managerial Control Oct 6, 2023
Adp of the SNF Oct 6, 2023
Individual Adp of the SNF Oct 6, 2023
GPN Family Trust U/a/D 4/28/08 Organization, Skokie, IL 5% Or Greater Direct Ownership Interest Oct 6, 2023 59.5%
Adp of the SNF Oct 6, 2023
Legacy Healthcare Financial Services LLC Organization, Skokie, IL LLC Operational/Managerial Control Oct 6, 2023
Adp of the SNF Nov 11, 2025
Oakway Operations LLC Organization, Skokie, IL LLC 5% Or Greater Direct Ownership Interest Oct 6, 2023 15%
Doros Generation Trust U/a/D 1/3/12 Organization, Skokie, IL 5% Or Greater Direct Ownership Interest Oct 6, 2023 25.5%
Adp of the SNF Oct 6, 2023
Individual Indirect Ownership Interest Oct 6, 2023 4.9%
Cibc Bank USA Organization, Chicago, IL Corporation 5% Or Greater Security Interest Oct 31, 2025 100%
Operational/Managerial Control Oct 31, 2025
Individual Indirect Ownership Interest Oct 6, 2023 4.9%
Individual Indirect Ownership Interest Oct 6, 2023 2.6%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 175

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 175

Practitioners & affiliated clinicians

Affiliated clinicians 4

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1682899200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682899200000",
    "number": "1386332906",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3450 OAKTON ST",
            "city": "SKOKIE",
            "state": "IL",
            "postal_code": "600762951",
            "telephone_number": "847-679-9797",
            "fax_number": "847-679-1126"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1366 W FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606142129",
            "telephone_number": "773-248-9300",
            "fax_number": "773-935-0036"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FULLERTON SKILLED NURSING FACILITY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-05-01",
        "last_updated": "2023-05-01",
        "certification_date": "2023-05-01",
        "status": "A",
        "authorized_official_last_name": "SHABAT",
        "authorized_official_first_name": "MENACHEM",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "773-248-9300"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avantara Lincoln Park",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.