Provider Demographics
NPI:1346062353
Name:2339 SOUTH SR 135 TENANT LLC
Entity type:Organization
Organization Name:2339 SOUTH SR 135 TENANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT OF ITS MANAGEMENT AGEN
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:ECHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:779-216-5849
Mailing Address - Street 1:200 E COURT ST STE 400
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3848
Mailing Address - Country:US
Mailing Address - Phone:815-935-1992
Mailing Address - Fax:815-935-8380
Practice Address - Street 1:2339 SOUTH STATE STREET ROAD 135
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-371-4803
Practice Address - Fax:317-535-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility