Basic Information
| Provider Information | |||||||||
| NPI: | 1164810420 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WC- OLNEY EG OPS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | EMERALD GLEN OLNEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 N EAST ST | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183954663 | ||||||||
| FaxNumber: | 6183926313 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 N EAST ST | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183954663 | ||||||||
| FaxNumber: | 6183926313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2015 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERVIN | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6183954663 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | IL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.