=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518073634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCK ISLAND SUPPORTIVE LIVING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 06/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 3RD AVENUE
-----------------------------------------------------
City | ROCK ISLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-786-0400
-----------------------------------------------------
Fax | 309-786-9729
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 3RD AVE.
-----------------------------------------------------
City | ROCK ISLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-786-0400
-----------------------------------------------------
Fax | 309-786-9729
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MARCI HALPERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-452-6804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------