Provider Demographics
NPI:1063974418
Name:EVERGREEN PLACE BEARDSTOWN LLC
Entity type:Organization
Organization Name:EVERGREEN PLACE BEARDSTOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC VP FINANCE & CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:115 W JEFFERSON ST STE 401
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3967
Mailing Address - Country:US
Mailing Address - Phone:309-823-7139
Mailing Address - Fax:
Practice Address - Street 1:8570 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-9200
Practice Address - Country:US
Practice Address - Phone:217-323-1860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility