1679995526 NPI number — BOLINGBROOK MEMORY CARE, LLC

Table of content: (NPI 1679995526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679995526 NPI number — BOLINGBROOK MEMORY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLINGBROOK MEMORY CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AUTUMN LEAVES OF BOLINGBROOK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679995526
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
545 E JOHN CARPENTER FWY
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75062-3931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-845-4500
Provider Business Mailing Address Fax Number:
214-845-4501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
351 LILY CACHE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLINGBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60440-3441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-759-0797
Provider Business Practice Location Address Fax Number:
630-759-1075
Provider Enumeration Date:
01/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FIELDS
Authorized Official First Name:
FELICHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF MANAGEMENT--SL
Authorized Official Telephone Number:
214-845-4454

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  5104283 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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