Organization
GLENWOOD HOUSE RESIDENTIAL CARE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RALPH S GOMES (PRESIDENT)
(815) 673-1182
Entity
Organization
Contact information
Practice address
300 W 12TH ST, STREATOR, IL 61364-3301
(815) 673-1182
(815) 673-3231
Mailing address
300 W 12TH ST, STREATOR, IL 61364-3301
(815) 673-1182
(815) 673-3231
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
0037192
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0037192
STATE LICENSE NUMBER
IL
Enumeration date
02/06/2008
Last updated
02/06/2008
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