Provider Demographics
NPI:1679995526
Name:BOLINGBROOK MEMORY CARE, LLC
Entity Type:Organization
Organization Name:BOLINGBROOK MEMORY CARE, LLC
Other - Org Name:AUTUMN LEAVES OF BOLINGBROOK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF MANAGEMENT--SL
Authorized Official - Prefix:
Authorized Official - First Name:FELICHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-845-4454
Mailing Address - Street 1:545 E JOHN CARPENTER FWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3931
Mailing Address - Country:US
Mailing Address - Phone:214-845-4500
Mailing Address - Fax:214-845-4501
Practice Address - Street 1:351 LILY CACHE LN
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3441
Practice Address - Country:US
Practice Address - Phone:630-759-0797
Practice Address - Fax:630-759-1075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5104283310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility