Healthcare Provider Details

I. General information

NPI: 1962435941
Provider Name (Legal Business Name): LTC ILLINOIS - FRIENDSHIP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MARTIN LUTHER KING
CENTRALIA IL
62801
US

IV. Provider business mailing address

925 N POINT PKWY SUITE 440
ALPHARETTA GA
30005-5210
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-3642
  • Fax: 618-533-3739
Mailing address:
  • Phone: 770-619-0866
  • Fax: 770-870-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0045682
License Number StateIL

VIII. Authorized Official

Name: MS. LOUANN ANSTIS
Title or Position: PRIVACY OFFICER
Credential:
Phone: 770-619-0866