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NPI Code Detail

MEDICARE: JACKSONVILLE CONVALESCENT CENTER, INC

MEDICARE: JACKSONVILLE CONVALESCENT CENTER, INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility0020131IL

General Provider Information

NPI Number : 1194977868
Entity Type Code : Organization
Provider Name (Legal Business Name) : JACKSONVILLE CONVALESCENT CENTER, INC
Provider Business Mailing Address
First Line : 2653 W LAWRENCE, SUITE B
Second Line :
City : SPRINGFIELD
State : IL
Zip : 62704
Country : US
Telephone Number : 217-787-8530
Fax Number : 217-787-9840
Provider Business Practice Location Address
First Line : 1517 W WALNUT ST
Second Line :
City : JACKSONVILLE
State : IL
Zip : 62650-1133
Country : US
Telephone Number : 217-243-6451
Fax Number : 217-243-8295
Authorized Official
Title or Position : CONTROLLER
Name : JERRY W JENNINGS
Credential :
Telephone Number : 217-787-8530
Provider Enumeration Date : 10/14/2008
Last Update Date : 10/14/2008

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