Provider Demographics
NPI:1790787679
Name:OUR LADY OF ANGELS RETIREMENT HOME
Entity Type:Organization
Organization Name:OUR LADY OF ANGELS RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-725-6631
Mailing Address - Street 1:1201 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3718
Mailing Address - Country:US
Mailing Address - Phone:815-725-6631
Mailing Address - Fax:815-725-1451
Practice Address - Street 1:1201 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3718
Practice Address - Country:US
Practice Address - Phone:815-725-6631
Practice Address - Fax:815-725-1451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility