MEDICARE: MENARD 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
1	314000000X	Skilled Nursing Facility	0003020	IL

General Provider Information

NPI Number	:	1720035611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENARD CONVALESCENT CENTER, INC

Provider Business Mailing Address
First Line	:	2653 W LAWRENCE AVE
Second Line	:	SUITE B
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-1115
Country	:	US
Telephone Number	:	217-787-8530
Fax Number	:	217-787-9840

Provider Business Practice Location Address
First Line	:	120 W ANTLE ST
Second Line	:
City	:	PETERSBURG
State	:	IL
Zip	:	62675-1035
Country	:	US
Telephone Number	:	217-632-2249
Fax Number	:	217-632-7810

Authorized Official
Title or Position	:	CONTROLLER
Name	:	JERRY JENNINGS
Credential	:
Telephone Number	:	217-787-8530

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	08/22/2020

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