Basic Information
| Provider Information | |||||||||
| NPI: | 1134345168 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRST CAREMERICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COLLINSVILLE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2810 FRANK SCOTT PARKWAY WEST | ||||||||
| Address2: | STE 824 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182349705 | ||||||||
| FaxNumber: | 6183550459 | ||||||||
| Practice Location | |||||||||
| Address1: | 614 N SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | COLLINSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183448476 | ||||||||
| FaxNumber: | 6183448483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RILEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182344705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0023309 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.