Provider Demographics
NPI:1831332402
Name:MARIANJOY AT PROVIDENCE DOWNER GROVE
Entity type:Organization
Organization Name:MARIANJOY AT PROVIDENCE DOWNER GROVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PFS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-909-7378
Mailing Address - Street 1:27 W 171 ROOSEVELT ROAD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-1141
Mailing Address - Country:US
Mailing Address - Phone:630-909-7378
Mailing Address - Fax:630-909-7371
Practice Address - Street 1:3450 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1141
Practice Address - Country:US
Practice Address - Phone:630-909-7370
Practice Address - Fax:630-909-7371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50425OtherBLUE CROSS BLUE SHIELD ILLINOIS