1821129974 NPI number — SPRINGFIELD SUPPORTIVE LIVING

Table of content: (NPI 1821129974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821129974 NPI number — SPRINGFIELD SUPPORTIVE LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGFIELD SUPPORTIVE LIVING
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:
Provider Other Organization Name Type Code:
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:
1821129974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4711 MIDLOTHIAN TPKE
Provider Second Line Business Mailing Address:
SUITE 20
Provider Business Mailing Address City Name:
CRESTWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60445-4900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-371-4507
Provider Business Mailing Address Fax Number:
708-371-1761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2034 E CLEAR LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62703-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-522-8843
Provider Business Practice Location Address Fax Number:
217-522-8803
Provider Enumeration Date:
03/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROECKELL
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
847-229-3400

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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