Provider Demographics
NPI:1962435941
Name:LTC ILLINOIS - FRIENDSHIP, INC.
Entity type:Organization
Organization Name:LTC ILLINOIS - FRIENDSHIP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LOUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-619-0866
Mailing Address - Street 1:925 N POINT PKWY
Mailing Address - Street 2:SUITE 440
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5210
Mailing Address - Country:US
Mailing Address - Phone:770-619-0866
Mailing Address - Fax:770-870-2892
Practice Address - Street 1:1000 MARTIN LUTHER KING
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-532-3642
Practice Address - Fax:618-533-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0045682314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
14-5817Medicare ID - Type Unspecified