Healthcare Provider Details

I. General information

NPI: 1427186451
Provider Name (Legal Business Name): STONEBRIDGE SENIOR LIVING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 S MCLEANSBORO ST
BENTON IL
62812-3413
US

IV. Provider business mailing address

902 S MCLEANSBORO ST PO BOX 968
BENTON IL
62812-3413
US

V. Phone/Fax

Practice location:
  • Phone: 618-439-4501
  • Fax: 618-435-3141
Mailing address:
  • Phone: 618-439-4501
  • Fax: 618-435-3141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0051888
License Number StateIL

VIII. Authorized Official

Name: MR. SCOTT E. STOUT
Title or Position: MANAGER
Credential:
Phone: 618-713-5284