Provider Demographics
NPI:1346210630
Name:FRIENDSHIP MANOR OF ST ELMO INC
Entity Type:Organization
Organization Name:FRIENDSHIP MANOR OF ST ELMO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-829-5581
Mailing Address - Street 1:221 E CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:ST ELMO
Mailing Address - State:IL
Mailing Address - Zip Code:62458-1662
Mailing Address - Country:US
Mailing Address - Phone:618-829-5581
Mailing Address - Fax:618-829-5569
Practice Address - Street 1:221 E CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:ST ELMO
Practice Address - State:IL
Practice Address - Zip Code:62458-1662
Practice Address - Country:US
Practice Address - Phone:618-829-5581
Practice Address - Fax:618-829-5569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0045583314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL14-5857Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER