Healthcare Provider Details

I. General information

NPI: 1558471714
Provider Name (Legal Business Name): WESLEY VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E GRANT ST
MACOMB IL
61455-3428
US

IV. Provider business mailing address

1200 E GRANT ST
MACOMB IL
61455-3428
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-2123
  • Fax: 309-837-7500
Mailing address:
  • Phone: 309-833-2123
  • Fax: 309-837-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0022350
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0022350
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. SHELLY L WARD
Title or Position: CEO/ ADMINISTRATOR
Credential: LWHA
Phone: 309-837-7500