Basic Information
| Provider Information | |||||||||
| NPI: | 1801125604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWESTERN NURSING & REHABILITATION CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND RIVER NURSING & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627032828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175282244 | ||||||||
| FaxNumber: | 2175283412 | ||||||||
| Practice Location | |||||||||
| Address1: | 2840 W CLAY ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369466100 | ||||||||
| FaxNumber: | 6369400998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2009 | ||||||||
| LastUpdateDate: | 03/01/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEDGES | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER OF LLC | ||||||||
| AuthorizedOfficialTelephone: | 2175282244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.