Provider Demographics
NPI:1225310246
Name:LUTHERAN RETIREMENT CENTER ASSOCIATION
Entity Type:Organization
Organization Name:LUTHERAN RETIREMENT CENTER ASSOCIATION
Other - Org Name:CONCORDIA VILLAGE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CHADWICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SNEED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-968-9313
Mailing Address - Street 1:4101 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7051
Mailing Address - Country:US
Mailing Address - Phone:217-793-9429
Mailing Address - Fax:217-793-1333
Practice Address - Street 1:4101 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7051
Practice Address - Country:US
Practice Address - Phone:217-793-9429
Practice Address - Fax:217-793-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0051078314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid