Healthcare Provider Details

I. General information

NPI: 1063518850
Provider Name (Legal Business Name): CARBONDALE REHABILITATION AND NURSING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N TOWER RD
CARBONDALE IL
62901-1929
US

IV. Provider business mailing address

8707 SKOKIE BLVD SUITE 310
SKOKIE IL
60077-2269
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-3355
  • Fax: 618-549-0484
Mailing address:
  • Phone: 708-236-0000
  • Fax: 708-236-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0041418
License Number StateIL

VIII. Authorized Official

Name: MR. STEVEN BLISKO
Title or Position: C.F.O
Credential:
Phone: 708-236-0000