Healthcare Provider Details

I. General information

NPI: 1013986439
Provider Name (Legal Business Name): NEW ATHENS HOME FOR THE AGED INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S JOHNSON ST
NEW ATHENS IL
62264-1319
US

IV. Provider business mailing address

203 S JOHNSON ST
NEW ATHENS IL
62264-1319
US

V. Phone/Fax

Practice location:
  • Phone: 618-475-2550
  • Fax: 618-475-2567
Mailing address:
  • Phone: 618-475-2550
  • Fax: 618-475-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0033043
License Number StateIL

VIII. Authorized Official

Name: MR. GARY WYNN HOLTGREWE
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-475-2550