Healthcare Provider Details

I. General information

NPI: 1780789693
Provider Name (Legal Business Name): WILLOW OF MARENGO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 E GRANT HWY
MARENGO IL
60152-3346
US

IV. Provider business mailing address

546 E GRANT HWY
MARENGO IL
60152-3346
US

V. Phone/Fax

Practice location:
  • Phone: 815-568-8322
  • Fax: 815-568-0135
Mailing address:
  • Phone: 815-568-8322
  • Fax: 815-568-0135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0041657
License Number StateIL

VIII. Authorized Official

Name: MR. JOSEPH BRANDMAN
Title or Position: COO
Credential:
Phone: 773-338-4400