Provider Demographics
NPI:1326866591
Name:BELLEVILLE VILLAS, LLC - BELLEVILLE OPERATION SERIES
Entity type:Organization
Organization Name:BELLEVILLE VILLAS, LLC - BELLEVILLE OPERATION SERIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:217-345-5022
Mailing Address - Street 1:2402 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-4343
Mailing Address - Country:US
Mailing Address - Phone:217-345-5022
Mailing Address - Fax:
Practice Address - Street 1:4350 FRANK SCOTT PKWY W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-6810
Practice Address - Country:US
Practice Address - Phone:618-744-0231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELLEVILLE VILLAS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility