Healthcare Provider Details

I. General information

NPI: 1902680069
Provider Name (Legal Business Name): WABASH SENIOR LIVING & REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 COLLEGE BLVD
CARMI IL
62821-1548
US

IV. Provider business mailing address

35 S VINE ST
HARRISBURG IL
62946-1738
US

V. Phone/Fax

Practice location:
  • Phone: 618-294-8699
  • Fax: 618-294-8699
Mailing address:
  • Phone: 618-294-8696
  • Fax: 618-294-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SCOTT E STOUT
Title or Position: CEO/OWNER
Credential: LNHA
Phone: 618-713-5284