Healthcare Provider Details

I. General information

NPI: 1063974418
Provider Name (Legal Business Name): EVERGREEN PLACE BEARDSTOWN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8570 SAINT LUKES DR
BEARDSTOWN IL
62618-9200
US

IV. Provider business mailing address

115 W JEFFERSON ST STE 401
BLOOMINGTON IL
61701-3967
US

V. Phone/Fax

Practice location:
  • Phone: 217-323-1860
  • Fax:
Mailing address:
  • Phone: 309-823-7139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID M UNDERWOOD
Title or Position: EXEC VP FINANCE & CFO
Credential:
Phone: 309-823-7135