Healthcare Provider Details

I. General information

NPI: 1386943306
Provider Name (Legal Business Name): THREE SPRINGS LODGE NURSING HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 THREE SPRINGS ROAD
CHESTER IL
62233-1064
US

IV. Provider business mailing address

161 THREE SPRINGS ROAD
CHESTER IL
62233-1064
US

V. Phone/Fax

Practice location:
  • Phone: 618-826-3210
  • Fax: 618-826-3821
Mailing address:
  • Phone: 618-826-3210
  • Fax: 618-826-3821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. KEN ROWOLD
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-826-3210