Basic Information
| Provider Information | |||||||||
| NPI: | 1003188913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN PLACE DECATUR, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVERGREEN PLACE DECATUR SUPPORTIVE LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 W JEFFERSON ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617013967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098237155 | ||||||||
| FaxNumber: | 3098299512 | ||||||||
| Practice Location | |||||||||
| Address1: | 4825 E EVERGREEN COURT | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178644300 | ||||||||
| FaxNumber: | 2178644321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2012 | ||||||||
| LastUpdateDate: | 02/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | ATER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098237135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | IL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.