Healthcare Provider Details

I. General information

NPI: 1912453358
Provider Name (Legal Business Name): CEP AMERICA - ILLINOIS SNF, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W E ST
BELLEVILLE IL
62220-1055
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-2095
  • Fax:
Mailing address:
  • Phone: 510-350-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: THEOPHILE KOURY
Title or Position: ADMINISTRATIVE VP OF OPERATIONS
Credential: MD
Phone: 510-350-2600