MEDICARE: GREENVILLE NURSING & REHABILITATION CENTER, LLC

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
1	314000000X	Skilled Nursing Facility	0046680	IL

General Provider Information

NPI Number	:	1235649054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENVILLE NURSING & REHABILITATION CENTER, LLC

Provider Business Mailing Address
First Line	:	105 S COMMERCIAL ST STE 1
Second Line	:
City	:	HARRISBURG
State	:	IL
Zip	:	62946-1939
Country	:	US
Telephone Number	:	618-294-8696
Fax Number	:	618-294-8699

Provider Business Practice Location Address
First Line	:	400 E HILLVIEW AVE
Second Line	:
City	:	GREENVILLE
State	:	IL
Zip	:	62246-2607
Country	:	US
Telephone Number	:	618-664-1622
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. SCOTT E STOUT
Credential	:
Telephone Number	:	618-294-8696

Provider Enumeration Date	:	10/06/2017
Last Update Date	:	10/06/2017

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