Provider Demographics
NPI:1285857284
Name:JOE JAC CORP.
Entity Type:Organization
Organization Name:JOE JAC CORP.
Other - Org Name:SPRING CREEK TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MAUPIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-422-6361
Mailing Address - Street 1:5310 E WILLIAM STREET RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-1874
Mailing Address - Country:US
Mailing Address - Phone:217-422-6361
Mailing Address - Fax:217-422-6365
Practice Address - Street 1:5310 E WILLIAM STREET RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-1874
Practice Address - Country:US
Practice Address - Phone:217-422-6361
Practice Address - Fax:217-422-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0045955315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6012314Medicaid