Healthcare Provider Details

I. General information

NPI: 1881015329
Provider Name (Legal Business Name): ST CLAIR SUPPORTIVE LIVING LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 KNOLLWOOD VILLAGE RD
CASEYVILLE IL
62232-1808
US

IV. Provider business mailing address

921 KNOLLWOOD VILLAGE RD
CASEYVILLE IL
62232-1808
US

V. Phone/Fax

Practice location:
  • Phone: 618-394-0569
  • Fax: 618-394-0582
Mailing address:
  • Phone: 618-394-0569
  • Fax: 618-394-0582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. LINDA RENEE BAKER
Title or Position: PRESIDENT, KNOLLWOOD MANAGEMENT
Credential: PH.D.
Phone: 618-394-0569