Provider Demographics
NPI:1346575636
Name:STONECREST MANOR ASSISTED LIVING
Entity Type:Organization
Organization Name:STONECREST MANOR ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GERI
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-472-2411
Mailing Address - Street 1:110 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:MOMENCE
Mailing Address - State:IL
Mailing Address - Zip Code:60954-1757
Mailing Address - Country:US
Mailing Address - Phone:815-472-2411
Mailing Address - Fax:815-472-2051
Practice Address - Street 1:110 HARVARD ST
Practice Address - Street 2:
Practice Address - City:MOMENCE
Practice Address - State:IL
Practice Address - Zip Code:60954-1757
Practice Address - Country:US
Practice Address - Phone:815-472-2411
Practice Address - Fax:815-472-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5101180310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility