Healthcare Provider Details

I. General information

NPI: 1659363661
Provider Name (Legal Business Name): CARAVILLA RESIDENTIAL CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 DOCTORS PARK RD
MOUNT VERNON IL
62864-6224
US

IV. Provider business mailing address

5 DOCTORS PARK RD
MOUNT VERNON IL
62864-6224
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-1064
  • Fax: 618-242-7559
Mailing address:
  • Phone: 618-242-1064
  • Fax: 618-242-7559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0039800
License Number StateIL

VIII. Authorized Official

Name: MICHAEL F FLANAGAN
Title or Position: CORPORATE ATTORNEY
Credential:
Phone: 816-444-0900