Healthcare Provider Details

I. General information

NPI: 1205824018
Provider Name (Legal Business Name): MACOMB SENIOR LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W GRANT ST
MACOMB IL
61455-2867
US

IV. Provider business mailing address

400 W GRANT ST
MACOMB IL
61455-2867
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-2386
  • Fax: 309-836-9191
Mailing address:
  • Phone: 309-837-2386
  • Fax: 309-836-9191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0043679
License Number StateIL

VIII. Authorized Official

Name: MRS. TAMMY SUE BONNEY
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 309-837-2386