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General NPI Number Information
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NPI Number | 1104012129
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Entity Type | Organization
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Legal Business Name | EMERALD GLEN MANAGEMENT
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Dates
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Enumeration Date | 09/24/2007
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Last Update Date | 09/24/2007
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Provider Practice Location Address
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Address Line | 18192 RENKEN ROAD
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City | STAUNTON
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State | IL
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Zip | 62088
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Country | US
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Telephone | 618-635-4012
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 771
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City | EFFINGHAM
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State | IL
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Zip | 62401
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Country | US
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Telephone | 217-821-9539
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | SHELLEY C NUELLE
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Credential |
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Telephone | 217-821-9539
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State | IL
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