Provider Demographics
NPI:1073509113
Name:CARRIER MILLS NURSING & REHABILITATION CENTER, INC
Entity type:Organization
Organization Name:CARRIER MILLS NURSING & REHABILITATION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:618-994-2323
Mailing Address - Street 1:6789 US HIGHWAY 45 S
Mailing Address - Street 2:P O BOX 68
Mailing Address - City:CARRIER MILLS
Mailing Address - State:IL
Mailing Address - Zip Code:62917-1225
Mailing Address - Country:US
Mailing Address - Phone:618-994-2323
Mailing Address - Fax:618-994-4082
Practice Address - Street 1:6789 US HIGHWAY 45 S
Practice Address - Street 2:
Practice Address - City:CARRIER MILLS
Practice Address - State:IL
Practice Address - Zip Code:62917-1225
Practice Address - Country:US
Practice Address - Phone:618-994-2323
Practice Address - Fax:618-994-4082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000025130314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37112696001Medicaid
IL145323Medicare Oscar/Certification