Healthcare Provider Details

I. General information

NPI: 1568614238
Provider Name (Legal Business Name): MEADOW MANOR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MCADAM DR
TAYLORVILLE IL
62568-9634
US

IV. Provider business mailing address

2653 W LAWRENCE AVE STE B
SPRINGFIELD IL
62704-1115
US

V. Phone/Fax

Practice location:
  • Phone: 217-824-2277
  • Fax: 217-287-7763
Mailing address:
  • Phone: 217-787-8530
  • Fax: 217-787-9840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0011528
License Number StateIL

VIII. Authorized Official

Name: JERRY W JENNINGS
Title or Position: CONTROLLER
Credential:
Phone: 217-787-8530