Provider Demographics
NPI:1821129974
Name:SPRINGFIELD SUPPORTIVE LIVING
Entity Type:Organization
Organization Name:SPRINGFIELD SUPPORTIVE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROECKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-229-3400
Mailing Address - Street 1:4711 MIDLOTHIAN TPKE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60445-4900
Mailing Address - Country:US
Mailing Address - Phone:708-371-4507
Mailing Address - Fax:708-371-1761
Practice Address - Street 1:2034 E CLEAR LAKE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1134
Practice Address - Country:US
Practice Address - Phone:217-522-8843
Practice Address - Fax:217-522-8803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid