Provider Demographics
NPI:1104814490
Name:PALLADIAN AVISTON SNF LLC
Entity type:Organization
Organization Name:PALLADIAN AVISTON SNF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-566-0459
Mailing Address - Street 1:1670 ESSEX WAY STE B
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3063
Mailing Address - Country:US
Mailing Address - Phone:618-327-3064
Mailing Address - Fax:618-327-3083
Practice Address - Street 1:450 W 1ST ST
Practice Address - Street 2:
Practice Address - City:AVISTON
Practice Address - State:IL
Practice Address - Zip Code:62216-3440
Practice Address - Country:US
Practice Address - Phone:618-228-7615
Practice Address - Fax:618-228-7632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1621197314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3712129346221601Medicaid
IL145601Medicare ID - Type Unspecified