Basic Information
| Provider Information | |||||||||
| NPI: | 1366436453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUR FOUNTAINS CONVALESCENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S BELT W | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622202503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182777700 | ||||||||
| FaxNumber: | 6183554050 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S BELT W | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622202503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182777700 | ||||||||
| FaxNumber: | 6183554050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 03/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCNITT | ||||||||
| AuthorizedOfficialFirstName: | HOPE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED NURSING HOME ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6182777700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | R.N. L.N.H.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376G00000X | 0030304 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Nursing Home Administrator |
No ID Information.