Healthcare Provider Details

I. General information

NPI: 1134557846
Provider Name (Legal Business Name): 222 STATE STREET PROPERTIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N STATE ST
CHAMPAIGN IL
61820-3937
US

IV. Provider business mailing address

222 N STATE ST
CHAMPAIGN IL
61820-3937
US

V. Phone/Fax

Practice location:
  • Phone: 217-903-5900
  • Fax: 217-378-6829
Mailing address:
  • Phone: 217-903-5900
  • Fax: 217-378-6829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY CROSS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 217-903-5900