Basic Information
Provider Information | |||||||||
NPI: | 1962435941 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LTC ILLINOIS - FRIENDSHIP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRIENDSHIP HOUSE OF CENTRALIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 925 N POINT PKWY | ||||||||
Address2: | SUITE 440 | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300055210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706190866 | ||||||||
FaxNumber: | 7708702892 | ||||||||
Practice Location | |||||||||
Address1: | 1000 MARTIN LUTHER KING | ||||||||
Address2: |   | ||||||||
City: | CENTRALIA | ||||||||
State: | IL | ||||||||
PostalCode: | 62801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185323642 | ||||||||
FaxNumber: | 6185333739 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2006 | ||||||||
LastUpdateDate: | 08/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANSTIS | ||||||||
AuthorizedOfficialFirstName: | LOUANN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRIVACY OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7706190866 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0045682 | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.