Provider Demographics
NPI:1558471714
Name:WESLEY VILLAGE
Entity Type:Organization
Organization Name:WESLEY VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:LWHA
Authorized Official - Phone:309-837-7500
Mailing Address - Street 1:1200 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3428
Mailing Address - Country:US
Mailing Address - Phone:309-833-2123
Mailing Address - Fax:309-837-7500
Practice Address - Street 1:1200 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3428
Practice Address - Country:US
Practice Address - Phone:309-833-2123
Practice Address - Fax:309-837-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0022350313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid