Basic Information
| Provider Information | |||||||||
| NPI: | 1194920058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILKINSON FOUNTAINS LEASE CO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE FOUNTAINS OF SHILOH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 CENTENNIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974017900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417473373 | ||||||||
| FaxNumber: | 5417470673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 HARTMAN LN | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622218402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082399282 | ||||||||
| FaxNumber: | 6182229305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOLTZ | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 5417473373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | Y | Managed Care Organizations | Point of Service |
No ID Information.