Fillable 4900 WEST 183RD STREET - idph state il

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PRINTED: 08/07/2009 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 14G271 NAME OF PROVIDER OR SUPPLIER OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 05/18/2009 STREET ADDRESS, CITY, STATE, ZIP CODE 4900 WEST 183RD STREET COUNTRY CLUB TERRACE (X4)...
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