Provider Demographics
NPI:1104012129
Name:EMERALD GLEN MANAGEMENT
Entity Type:Organization
Organization Name:EMERALD GLEN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NUELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-821-9539
Mailing Address - Street 1:PO BOX 771
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-821-9539
Mailing Address - Fax:
Practice Address - Street 1:18192 RENKEN ROAD
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088
Practice Address - Country:US
Practice Address - Phone:618-635-4012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility