Basic Information
| Provider Information | |||||||||
| NPI: | 1205824018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MACOMB SENIOR LIVING CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 W GRANT ST | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614552867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098372386 | ||||||||
| FaxNumber: | 3098369191 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W GRANT ST | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614552867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098372386 | ||||||||
| FaxNumber: | 3098369191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BONNEY | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3098372386 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0043679 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.