Provider Demographics
NPI:1205824018
Name:MACOMB SENIOR LIVING CENTER
Entity Type:Organization
Organization Name:MACOMB SENIOR LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BONNEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:309-837-2386
Mailing Address - Street 1:400 W GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2867
Mailing Address - Country:US
Mailing Address - Phone:309-837-2386
Mailing Address - Fax:309-836-9191
Practice Address - Street 1:400 W GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2867
Practice Address - Country:US
Practice Address - Phone:309-837-2386
Practice Address - Fax:309-836-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0043679314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========036Medicaid
IL=========036Medicaid