Provider Demographics
NPI:1235228016
Name:D MILLER INNOVATIVE CARE INC
Entity Type:Organization
Organization Name:D MILLER INNOVATIVE CARE INC
Other - Org Name:CRAWFORD COUNTY CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-546-5638
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:902 W MEFFORD STREET
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454
Mailing Address - Country:US
Mailing Address - Phone:618-546-5638
Mailing Address - Fax:618-544-7068
Practice Address - Street 1:902 W MEFFORD STREET
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454
Practice Address - Country:US
Practice Address - Phone:618-546-5638
Practice Address - Fax:618-544-7068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0029645313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0662232Medicaid
14E340Medicare ID - Type Unspecified