Healthcare Provider Details

I. General information

NPI: 1295980852
Provider Name (Legal Business Name): EVERGREEN STREATOR, L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 E MAIN ST
STREATOR IL
61364-3162
US

IV. Provider business mailing address

115 W JEFFERSON ST STE 401, PO BOX 3188
BLOOMINGTON IL
61701-3946
US

V. Phone/Fax

Practice location:
  • Phone: 815-672-0903
  • Fax: 815-672-0639
Mailing address:
  • Phone: 309-823-7155
  • Fax: 309-829-9512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CRAIG L. ATER
Title or Position: SENIOR V.P. OF FINANCE
Credential:
Phone: 309-828-4361