Basic Information
| Provider Information | |||||||||
| NPI: | 1184774465 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENBRIER LODGE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | GREENBRIER HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 600 S. MAPLE STREET | ||||||||
| Address2: | |||||||||
| City: | PIPER CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156862277 | ||||||||
| FaxNumber: | 8156862812 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S. MAPLE STREET | ||||||||
| Address2: | |||||||||
| City: | PIPER CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156862277 | ||||||||
| FaxNumber: | 8156862812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ATER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR V.P. OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3098284361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0044487 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.