Provider Demographics
NPI:1275707127
Name:BENJAMIN GREEN FIELD RESIDENCE
Entity Type:Organization
Organization Name:BENJAMIN GREEN FIELD RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:PATRIICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:847-990-3710
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-0520
Mailing Address - Country:US
Mailing Address - Phone:847-362-4636
Mailing Address - Fax:847-362-0742
Practice Address - Street 1:14245 W ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-9713
Practice Address - Country:US
Practice Address - Phone:847-362-4636
Practice Address - Fax:847-362-0742
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LAMBS FARM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000041582315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid