Provider Demographics
NPI:1073069209
Name:DOWNERS GROVE SUPPORTIVE LIVING LLC
Entity Type:Organization
Organization Name:DOWNERS GROVE SUPPORTIVE LIVING LLC
Other - Org Name:LACEY CREEK SUPPORTIVE LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF MANAGEMENT AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEAVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-1992
Mailing Address - Street 1:4200 LACEY ROAD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:630-964-7720
Mailing Address - Fax:630-964-4229
Practice Address - Street 1:4200 LACEY ROAD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515
Practice Address - Country:US
Practice Address - Phone:630-964-7720
Practice Address - Fax:630-964-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility