1093360984 NPI number — GLASSWATER CREEK OF PLAINFIELD, LLC

Table of content: (NPI 1093360984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093360984 NPI number — GLASSWATER CREEK OF PLAINFIELD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLASSWATER CREEK OF PLAINFIELD, 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:
Provider Other Organization Name Type Code:
6
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:
1093360984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 E COURT ST STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-3848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-935-1992
Provider Business Mailing Address Fax Number:
815-935-8380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10480 GLASSWATER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46231-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-839-5808
Provider Business Practice Location Address Fax Number:
317-839-5826
Provider Enumeration Date:
08/07/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ECHOLS
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-PRESIDENT OF MANAGEMENT AGENT
Authorized Official Telephone Number:
815-935-1992

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)





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