Provider Demographics
NPI:1205014727
Name:GLENWOOD HOUSE RESIDENTIAL CARE, INC.
Entity Type:Organization
Organization Name:GLENWOOD HOUSE RESIDENTIAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-673-1182
Mailing Address - Street 1:300 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-3301
Mailing Address - Country:US
Mailing Address - Phone:815-673-1182
Mailing Address - Fax:815-673-3231
Practice Address - Street 1:300 W 12TH ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-3301
Practice Address - Country:US
Practice Address - Phone:815-673-1182
Practice Address - Fax:815-673-3231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0037192315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0037192OtherSTATE LICENSE NUMBER