Healthcare Provider Details

I. General information

NPI: 1679647887
Provider Name (Legal Business Name): LAKEWOOD SENIOR LIVING OF MATTOON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 S 9TH ST
MATTOON IL
61938-6113
US

IV. Provider business mailing address

3008 7TH AVE S
BIRMINGHAM AL
35233-3503
US

V. Phone/Fax

Practice location:
  • Phone: 217-235-7138
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0047860
License Number StateIL

VIII. Authorized Official

Name: THOMAS KENT
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 205-320-7554