Healthcare Provider Details

I. General information

NPI: 1497755094
Provider Name (Legal Business Name): EDWARDSVILLE HEALTH CARE CENTER INVESTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 UNIVERSITY DR
EDWARDSVILLE IL
62025-3961
US

IV. Provider business mailing address

1095 UNIVERSITY DR
EDWARDSVILLE IL
62025-3961
US

V. Phone/Fax

Practice location:
  • Phone: 618-656-1081
  • Fax: 618-656-7083
Mailing address:
  • Phone: 618-656-1081
  • Fax: 618-656-7083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0046557
License Number StateIL

VIII. Authorized Official

Name: MRS. KIMBERLY A WOOD
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 618-656-1081