Healthcare Provider Details

I. General information

NPI: 1326866591
Provider Name (Legal Business Name): BELLEVILLE VILLAS, LLC - BELLEVILLE OPERATION SERIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 FRANK SCOTT PKWY W
BELLEVILLE IL
62223-6810
US

IV. Provider business mailing address

2402 18TH ST
CHARLESTON IL
61920-4343
US

V. Phone/Fax

Practice location:
  • Phone: 618-744-0231
  • Fax:
Mailing address:
  • Phone: 217-345-5022
  • 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: MR. RANDY PORTER
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CFO
Phone: 217-345-5022