Healthcare Provider Details

I. General information

NPI: 1689795379
Provider Name (Legal Business Name): SSC MOUNT VERNON OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S 34TH ST
MOUNT VERNON IL
62864-6232
US

IV. Provider business mailing address

5300 W SAM HOUSTON PKWY N SUITE 100
HOUSTON TX
77041-5161
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-5700
  • Fax:
Mailing address:
  • Phone: 832-467-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1733907
License Number StateIL

VIII. Authorized Official

Name: KELLE C SANTORO
Title or Position: SR DIRECTOR AR
Credential:
Phone: 832-467-5728