=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073509113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARRIER MILLS NURSING & REHABILITATION CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2005
-----------------------------------------------------
Last Update Date | 02/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6789 US HIGHWAY 45 S
-----------------------------------------------------
City | CARRIER MILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62917-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-994-2323
-----------------------------------------------------
Fax | 618-994-4082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6789 US HIGHWAY 45 S P O BOX 68
-----------------------------------------------------
City | CARRIER MILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62917-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-994-2323
-----------------------------------------------------
Fax | 618-994-4082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. SCOT E. STOUT
-----------------------------------------------------
Credential | LNHA
-----------------------------------------------------
Telephone | 618-994-2323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 000025130
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------