Healthcare Provider Details

I. General information

NPI: 1487926622
Provider Name (Legal Business Name): MEMORY CARE COMMUNITIES OF ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 VELLAGIO DR
SYCAMORE IL
60178-7800
US

IV. Provider business mailing address

175 OLDE HALF DAY RD SUITE 292
LINCOLNSHIRE IL
60069-3061
US

V. Phone/Fax

Practice location:
  • Phone: 815-895-9870
  • Fax:
Mailing address:
  • Phone: 847-777-6933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5013475
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number5103475
License Number StateIL

VIII. Authorized Official

Name: MR. STEVEN LIRTZMAN
Title or Position: MEMBER
Credential:
Phone: 847-777-6933