Provider Demographics
NPI:1831634146
Name:MINOOKA SUPPORTIVE LIVING FACILITY, LLC
Entity type:Organization
Organization Name:MINOOKA SUPPORTIVE LIVING FACILITY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF MANAGEMENT AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEAVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-1992
Mailing Address - Street 1:701 HERITAGE WOODS DR
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-8281
Mailing Address - Country:US
Mailing Address - Phone:815-467-2837
Mailing Address - Fax:815-467-2783
Practice Address - Street 1:701 HERITAGE WOODS DR
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-8281
Practice Address - Country:US
Practice Address - Phone:815-467-2837
Practice Address - Fax:815-467-2783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility