ig-oci OR IC! ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT- 02/2017 Edition ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT SECTION I. IDENTIFICATION, GENERAL INFORMATION, AND CERTIFICATION This Section must be completed for all projects. Facility/Project Identification Facility Name: Garfield Kidney Center Street Address: 408 — 418 North Homan Avenue City and Zip Code: Chicago, Illinois 60624 County: Cook Health Service Area: 6 Health Planning Area: 6 licant (refer to Part 1130.220 Exact Legal Name: DaVita Inc. Street Address: 2000 16m Street City and Zip Code: Denver, CO 80202 Name of Registered Agent: Illinois Corporation Service Company _f_tegistered Agent Street Address: 801 Adlai Stevenson Drive Registered Agent City and Zip Code: Springfield, Illinois 62703 Name of Chief Executive Officer: Kent Thiry CEO Street Address: 2000 16m Street CEO City and Zip Code: Denver, CO 80202 CEO Telephone Number: 303-405-2100 _Type of Ownership of Applicants • Non-profit Corporation • Partnership • For-profit Corporation O Governmental ▪ Limited Liability Company o Sole Proprietorship P Other o Corporations and limited liability companies must provide an Illinois certificate of good standing. o Partnerships must provide the name of the state in which they are organized and the name and address of each partner specifying whether each is a general or limited partner. APPEND DOCUMENTATION AS ATTACHMENT 1 IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. ontact IPerson to receive ALL correspondence or in uiries Name: Tim Tincknell Title: Administrator Company Name: DaVita Inc. Address: 2484 North Elston Avenue, Chicago, Illinois 60647 Telephone Number: 773-278-4403 E-mail Address:
[email protected] Fax Number: 866-586-3214 Additional Contact Person who is also authorized to discuss the application for permit Name: Brent Habitz Title: Regional Operations Director Company Name: DaVita Inc.