Provider Demographics
NPI:1942407200
Name:CAMBRIDGE HOUSE OF MARYVILLE
Entity Type:Organization
Organization Name:CAMBRIDGE HOUSE OF MARYVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:618-288-2211
Mailing Address - Street 1:6960 STATE ROUTE 162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8532
Mailing Address - Country:US
Mailing Address - Phone:618-288-2211
Mailing Address - Fax:618-288-2299
Practice Address - Street 1:6960 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8532
Practice Address - Country:US
Practice Address - Phone:618-288-2211
Practice Address - Fax:618-288-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility