1780789693 NPI number — WILLOW OF MARENGO, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780789693 NPI number — WILLOW OF MARENGO, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOW OF MARENGO, INC
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:
1780789693
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:
546 E GRANT HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARENGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60152-3346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-568-8322
Provider Business Mailing Address Fax Number:
815-568-0135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
546 E GRANT HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARENGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60152-3346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-568-8322
Provider Business Practice Location Address Fax Number:
815-568-0135
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRANDMAN
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
773-338-4400

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0041657 , 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)

  • Identifier: 6003180 . This is a "FACILITY ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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