Basic Information
| Provider Information | |||||||||
| NPI: | 1699868257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEVERLY ENTERPRISES - ILLINOIS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BLU FOUNTAIN MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1623 W. DELMAR | ||||||||
| Address2: | #29 | ||||||||
| City: | GODFREY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184660443 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1623 W. DELMAR | ||||||||
| Address2: | #29 | ||||||||
| City: | GODFREY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184660443 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERRELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4792014840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 53511 | 01 | IL | GROUP HP | OTHER | 105286 | 01 | IL | BCBS | OTHER |