1811984644 NPI number — EASTVIEW TERRACE

Table of content: (NPI 1811984644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811984644 NPI number — EASTVIEW TERRACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTVIEW TERRACE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811984644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 EASTVIEW PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SULLIVAN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61951-1674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-728-7367
Provider Business Mailing Address Fax Number:
217-728-2112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 EASTVIEW PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SULLIVAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61951-1674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-728-7367
Provider Business Practice Location Address Fax Number:
217-728-2112
Provider Enumeration Date:
10/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REEDY
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
CAREPLAN COORDINATOR
Authorized Official Telephone Number:
217-728-7367

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0046060 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 371346306007 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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