Healthcare Provider Details

I. General information

NPI: 1518339167
Provider Name (Legal Business Name): PRAIRIE VILLAGE SUPPORTIVE LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 INTERNATIONAL DRIVE
RANTOUL IL
61866
US

IV. Provider business mailing address

200 INTERNATIONAL DRIVE
RANTOUL IL
61866
US

V. Phone/Fax

Practice location:
  • Phone: 217-892-2800
  • Fax: 217-892-2833
Mailing address:
  • Phone: 217-892-2800
  • Fax: 217-892-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: JOELLEN BLEAVINS
Title or Position: VICE PRESIDENT OF MANAGEMENT AGENT
Credential:
Phone: 815-935-1992