Healthcare Provider Details

I. General information

NPI: 1508956459
Provider Name (Legal Business Name): CHARLESTON HCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 18TH ST
CHARLESTON IL
61920-2382
US

IV. Provider business mailing address

716 18TH ST
CHARLESTON IL
61920-2382
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-7054
  • Fax: 217-348-1264
Mailing address:
  • Phone: 217-345-7054
  • Fax: 816-276-0150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0040311
License Number StateIL

VIII. Authorized Official

Name: STEPHANIE REDBURN
Title or Position: REVENUE CYCLE COMPLIANCE AUDITOR
Credential:
Phone: 816-444-0900