Provider Demographics
NPI:1033396890
Name:PEACE VILLAGE
Entity Type:Organization
Organization Name:PEACE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELLENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-671-2403
Mailing Address - Street 1:10300 VILLAGE CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-3541
Mailing Address - Country:US
Mailing Address - Phone:708-671-2403
Mailing Address - Fax:708-671-2453
Practice Address - Street 1:10300 VILLAGE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-3541
Practice Address - Country:US
Practice Address - Phone:708-671-2403
Practice Address - Fax:708-671-2453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5101065310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility