Healthcare Provider Details

I. General information

NPI: 1215403241
Provider Name (Legal Business Name): CEP AMERICA - ILLINOIS SNF, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W LINCOLN AVE
CASEYVILLE IL
62232-1306
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1844
US

V. Phone/Fax

Practice location:
  • Phone: 618-345-3072
  • 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

VIII. Authorized Official

Name: THEOPHILE G. KOURY
Title or Position: ADMINISTRATIVE VICE PRESIDENT
Credential:
Phone: 510-350-2600