Provider Demographics
NPI:1417144775
Name:VICTORY CENTRE OF JOLIET LLC
Entity Type:Organization
Organization Name:VICTORY CENTRE OF JOLIET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT OF GARDANT MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:ECHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:779-216-5849
Mailing Address - Street 1:30 S WACKER DR STE 1010
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-7413
Mailing Address - Country:US
Mailing Address - Phone:312-837-0701
Mailing Address - Fax:312-837-0728
Practice Address - Street 1:29 N BROADWAY
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-7400
Practice Address - Country:US
Practice Address - Phone:815-724-0308
Practice Address - Fax:815-723-2956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364273297001Medicaid