Provider Demographics
NPI:1598315376
Name:THE VILLAGE AT MERCY CREEK
Entity Type:Organization
Organization Name:THE VILLAGE AT MERCY CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF CLINICAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MS, LNHA
Authorized Official - Phone:331-318-5120
Mailing Address - Street 1:11500 THERESA DR
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-2727
Mailing Address - Country:US
Mailing Address - Phone:331-318-5120
Mailing Address - Fax:331-318-5210
Practice Address - Street 1:1501 MERCY CREEK DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-9597
Practice Address - Country:US
Practice Address - Phone:309-268-1501
Practice Address - Fax:309-268-1498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility