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General NPI Number Information
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NPI Number | 1346062353
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Entity Type | Organization
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Legal Business Name | 2339 SOUTH SR 135 TENANT LLC
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Dates
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Enumeration Date | 10/30/2024
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 2339 SOUTH STATE STREET ROAD 135
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City | GREENWOOD
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State | IN
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Zip | 46143
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Country | US
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Telephone | 317-371-4803
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Fax | 317-535-0425
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Provider Business Mailing Address
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Address Line | 200 E COURT ST STE 400
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City | KANKAKEE
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State | IL
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Zip | 60901-3848
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Country | US
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Telephone | 815-935-1992
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Fax | 815-935-8380
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Authorized Official
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Title or Position | CO-PRESIDENT OF ITS MANAGEMENT AGEN
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Name | MR. GREG ECHOLS
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Credential |
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Telephone | 779-216-5849
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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 |
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