Healthcare Provider Details

I. General information

NPI: 1417028168
Provider Name (Legal Business Name): GENERAL BAPTIST NURSING HOME OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 W. 9TH STREET
MT. CARMEL IL
62863
US

IV. Provider business mailing address

1320 W. 9TH ST.
MT. CARMEL IL
62863
US

V. Phone/Fax

Practice location:
  • Phone: 618-263-4337
  • Fax: 618-262-7080
Mailing address:
  • Phone: 618-263-4337
  • Fax: 618-262-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0026328
License Number StateIL

VIII. Authorized Official

Name: MR. SCOTT R COLE
Title or Position: CEO
Credential:
Phone: 870-598-1020