Basic Information
| Provider Information | |||||||||
| NPI: | 1629247283 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEAN COUNTY ASSISTED LIVING, L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EVERGREEN VILLAGE SUPPORTIVE LIVING, L.L.C. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 W JEFFERSON ST | ||||||||
| Address2: | SUITE 401, PO BOX 3188 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617013946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098237155 | ||||||||
| FaxNumber: | 3098299512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 EVERGREEN VILLAGE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094527300 | ||||||||
| FaxNumber: | 3094527311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2008 | ||||||||
| LastUpdateDate: | 08/06/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ATER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR V. P. OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3098237135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLEAN COUNTY ASSISTED LIVING, L.L.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | IL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 205051684001 | 05 | IL | MEDICAID |