Provider Demographics
NPI:1124152384
Name:WEST GROVE, INC
Entity type:Organization
Organization Name:WEST GROVE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-945-2091
Mailing Address - Street 1:RR 1 BOX 417
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-9796
Mailing Address - Country:US
Mailing Address - Phone:618-943-7597
Mailing Address - Fax:618-943-3218
Practice Address - Street 1:RR 1 BOX 417
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-9796
Practice Address - Country:US
Practice Address - Phone:618-943-7597
Practice Address - Fax:618-943-3218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0033548320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities