Basic Information
| Provider Information | |||||||||
| NPI: | 1912453358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEP AMERICA - ILLINOIS SNF, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | STE 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1021 W E ST | ||||||||
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| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182332095 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2016 | ||||||||
| LastUpdateDate: | 08/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | KOURY | ||||||||
| AuthorizedOfficialFirstName: | THEOPHILE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5103502600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.