Healthcare Provider Details

I. General information

NPI: 1386925535
Provider Name (Legal Business Name): TERRACE ON THE PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N 10TH ST
MASCOUTAH IL
62258-1017
US

IV. Provider business mailing address

901 N 10TH ST
MASCOUTAH IL
62258-1017
US

V. Phone/Fax

Practice location:
  • Phone: 618-566-2183
  • Fax: 618-566-4462
Mailing address:
  • Phone: 618-566-2183
  • Fax: 618-566-4462

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: MOSHE DAVID ARYEH
Title or Position: MEMBER/MANAGER
Credential:
Phone: 847-440-2233