Healthcare Provider Details

I. General information

NPI: 1790787679
Provider Name (Legal Business Name): OUR LADY OF ANGELS RETIREMENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 WYOMING AVE
JOLIET IL
60435-3718
US

IV. Provider business mailing address

1201 WYOMING AVE
JOLIET IL
60435-3718
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-6631
  • Fax: 815-725-1451
Mailing address:
  • Phone: 815-725-6631
  • Fax: 815-725-1451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: GEORGE BLOCK
Title or Position: ADMINISTRATOR
Credential:
Phone: 815-725-6631