Provider Demographics
NPI:1780789693
Name:WILLOW OF MARENGO, INC
Entity type:Organization
Organization Name:WILLOW OF MARENGO, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-338-4400
Mailing Address - Street 1:546 E GRANT HWY
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-3346
Mailing Address - Country:US
Mailing Address - Phone:815-568-8322
Mailing Address - Fax:815-568-0135
Practice Address - Street 1:546 E GRANT HWY
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-3346
Practice Address - Country:US
Practice Address - Phone:815-568-8322
Practice Address - Fax:815-568-0135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0041657314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6003180OtherFACILITY ID