Basic Information
| Provider Information | |||||||||
| NPI: | 1710946801 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RED BUD ILLINOIS HOSPITAL COMPANY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | RED BUD NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 503891 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631503891 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 W SOUTH 1ST ST | ||||||||
| Address2: | |||||||||
| City: | RED BUD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622781116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182823891 | ||||||||
| FaxNumber: | 6182824070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP FINANCE OP/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152213840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RED BUD ILLINOIS HOSPITAL COMPANY LLC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 0045476 | IL | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.