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General NPI Number Information
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NPI Number | 1871312033
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Entity Type | Organization
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Legal Business Name | PHILLIPS WARNER RANTOUL, LLC - RANTOUL OPERATIONS SERIES
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Dates
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Enumeration Date | 10/05/2024
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 722 STONEBRIDGE CTR RD
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City | RANTOUL
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State | IL
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Zip | 61866-2159
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Country | US
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Telephone | 217-282-9854
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Fax |
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Provider Business Mailing Address
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Address Line | 2402 18TH ST
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City | CHARLESTON
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State | IL
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Zip | 61920-4343
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Country | US
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Telephone | 217-345-5022
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | RANDY PORTER
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Credential | CFO
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Telephone | 217-345-5022
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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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