MEDICARE: IMBODEN CREEK SENIOR LIVING & REHABILITATION 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1790446383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMBODEN CREEK SENIOR LIVING & REHABILITATION LLC

Provider Business Mailing Address
First Line	:	215 E LOCUST ST
Second Line	:
City	:	HARRISBURG
State	:	IL
Zip	:	62946-1504
Country	:	US
Telephone Number	:	618-294-8696
Fax Number	:	618-294-8699

Provider Business Practice Location Address
First Line	:	180 W IMBODEN DR
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62521-5238
Country	:	US
Telephone Number	:	217-422-6464
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SCOTT E STOUT
Credential	:	LNHA
Telephone Number	:	618-294-8696

Provider Enumeration Date	:	01/05/2022
Last Update Date	:	04/25/2022

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