Basic Information
| Provider Information | |||||||||
| NPI: | 1750526232 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRILOGY HEALTHCARE OF WILL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. JAMES MANOR AND VILLAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1251 E RICHTON RD | ||||||||
| Address2: | |||||||||
| City: | CRETE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604171623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086726700 | ||||||||
| FaxNumber: | 7083674405 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 E RICHTON RD | ||||||||
| Address2: | |||||||||
| City: | CRETE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604171623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086726700 | ||||||||
| FaxNumber: | 7083674405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2008 | ||||||||
| LastUpdateDate: | 11/11/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PLEVYAK | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP - FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5022131710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRILOGY FSC INVESTORS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1870437 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0045435 | 05 | IL | MEDICAID |