Provider Demographics
NPI:1699868257
Name:BEVERLY ENTERPRISES - ILLINOIS, INC.
Entity type:Organization
Organization Name:BEVERLY ENTERPRISES - ILLINOIS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-201-4840
Mailing Address - Street 1:1623 W. DELMAR
Mailing Address - Street 2:#29
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035
Mailing Address - Country:US
Mailing Address - Phone:618-466-0443
Mailing Address - Fax:
Practice Address - Street 1:1623 W. DELMAR
Practice Address - Street 2:#29
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035
Practice Address - Country:US
Practice Address - Phone:618-466-0443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL53511OtherGROUP HP
IL105286OtherBCBS
IL=========002Medicaid