Provider Demographics
NPI:1174912562
Name:MARIANJOY AT PROVIDENCE VICTORIAN VILLAGE
Entity type:Organization
Organization Name:MARIANJOY AT PROVIDENCE VICTORIAN VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PFS CONTRACTED LEAD
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-909-7374
Mailing Address - Street 1:12525 RENAISSANCE CIR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-5896
Mailing Address - Country:US
Mailing Address - Phone:708-590-5050
Mailing Address - Fax:
Practice Address - Street 1:12525 RENAISSANCE CIR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-5896
Practice Address - Country:US
Practice Address - Phone:708-590-5050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
143027Medicare UPIN