Provider Demographics
NPI:1003188913
Name:EVERGREEN PLACE DECATUR, LLC
Entity Type:Organization
Organization Name:EVERGREEN PLACE DECATUR, LLC
Other - Org Name:EVERGREEN PLACE DECATUR SUPPORTIVE LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:115 W JEFFERSON ST STE 401
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3967
Mailing Address - Country:US
Mailing Address - Phone:309-823-7155
Mailing Address - Fax:309-829-9512
Practice Address - Street 1:4825 E EVERGREEN COURT
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-864-4300
Practice Address - Fax:217-864-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility