Downers Grove Supportive Living LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

DOWNERS GROVE SUPPORTIVE LIVING LLC

Doing business as

Lacey Creek Supportive LIving

Practice address

4200 Lacey Road
Downers Grove, IL 60515

Phone

(630) 964-7720

Fax

(630) 964-4229

NPI assigned

Aug 28, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Joellen Bleavins

Title

President of Management Agent

Phone

(815) 935-1992

Specialties & licenses 1

Addresses

Other names 1

• Lacey Creek Supportive LIving Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1472342400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472342400000",
    "number": "1073069209",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4200 LACEY ROAD",
            "city": "DOWNERS GROVE",
            "state": "IL",
            "postal_code": "60515",
            "telephone_number": "630-964-7720",
            "fax_number": "630-964-4229"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4200 LACEY ROAD",
            "city": "DOWNERS GROVE",
            "state": "IL",
            "postal_code": "60515",
            "telephone_number": "630-964-7720",
            "fax_number": "630-964-4229"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DOWNERS GROVE SUPPORTIVE LIVING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-08-28",
        "last_updated": "2016-08-28",
        "status": "A",
        "authorized_official_last_name": "BLEAVINS",
        "authorized_official_first_name": "JOELLEN",
        "authorized_official_title_or_position": "PRESIDENT OF MANAGEMENT AGENT",
        "authorized_official_telephone_number": "815-935-1992"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lacey Creek Supportive LIving",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.