MEDICARE: WC- RANTOUL OPS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility		IL

General Provider Information

NPI Number	:	1396133658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WC- RANTOUL OPS, LLC

Provider Business Mailing Address
First Line	:	300 TWIN LAKES DR
Second Line	:
City	:	RANTOUL
State	:	IL
Zip	:	61866-2663
Country	:	US
Telephone Number	:	217-892-5871
Fax Number	:	217-892-2128

Provider Business Practice Location Address
First Line	:	300 TWIN LAKES DR
Second Line	:
City	:	RANTOUL
State	:	IL
Zip	:	61866-2663
Country	:	US
Telephone Number	:	217-892-5871
Fax Number	:	217-892-2128

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	KATHY LANTZ
Credential	:
Telephone Number	:	217-892-5871

Provider Enumeration Date	:	01/08/2015
Last Update Date	:	01/13/2015

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