=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336428937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERSEYVILLE ESTATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2011
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 E FAIRGROUND AVE
-----------------------------------------------------
City | JERSEYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62052-1153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-639-9700
-----------------------------------------------------
Fax | 618-639-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 E FAIRGROUND AVE
-----------------------------------------------------
City | JERSEYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62052-1153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-639-9700
-----------------------------------------------------
Fax | 618-639-9701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING GENERAL PARTNER
-----------------------------------------------------
Name | JAMES MICHAEL GREER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-639-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 0001
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------