Healthcare Provider Details

I. General information

NPI: 1871582916
Provider Name (Legal Business Name): FRIENDSHIP MANOR INVESTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S FRIENDSHIP DR
NASHVILLE IL
62263-1363
US

IV. Provider business mailing address

485 S FRIENDSHIP DR
NASHVILLE IL
62263-1363
US

V. Phone/Fax

Practice location:
  • Phone: 618-327-3041
  • Fax: 618-327-4001
Mailing address:
  • Phone: 618-327-3041
  • Fax: 618-327-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0045922
License Number StateIL

VIII. Authorized Official

Name: MR. MARK IDE
Title or Position: PRESIDENT
Credential:
Phone: 317-670-1577