Provider Demographics
NPI:1497884696
Name:PLYMOUTH PLACE, INC.
Entity Type:Organization
Organization Name:PLYMOUTH PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:LILBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-482-6668
Mailing Address - Street 1:315 N. LA GRANGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-5695
Mailing Address - Country:US
Mailing Address - Phone:708-482-6668
Mailing Address - Fax:
Practice Address - Street 1:315 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1903
Practice Address - Country:US
Practice Address - Phone:708-482-6668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0012898314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146128Medicare Oscar/Certification