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General NPI Number Information
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NPI Number | 1497884696
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Entity Type | Organization
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Legal Business Name | PLYMOUTH PLACE, INC.
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 07/29/2013
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Provider Practice Location Address
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Address Line | 315 N LA GRANGE RD
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City | LA GRANGE PARK
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State | IL
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Zip | 60526-1903
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Country | US
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Telephone | 708-482-6668
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Fax |
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Provider Business Mailing Address
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Address Line | 315 N. LA GRANGE ROAD
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City | LA GRANGE PARK
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State | IL
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Zip | 60526-5695
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Country | US
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Telephone | 708-482-6668
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Fax |
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Authorized Official
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Title or Position | C.E.O.
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Name | MR. DALE LILBURN
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Credential |
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Telephone | 708-482-6668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 0012898
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License Number State | IL
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