Provider Demographics
NPI:1376798777
Name:EVERGREEN LITCHFIELD, L.P.
Entity Type:Organization
Organization Name:EVERGREEN LITCHFIELD, L.P.
Other - Org Name:EVERGREEN PLACE OF LITCHFIELD SUPPORTIVE LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOE V.P. OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-4361
Mailing Address - Street 1:115 W JEFFERSON ST
Mailing Address - Street 2:SUITE 401, BOX 3188
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3946
Mailing Address - Country:US
Mailing Address - Phone:309-823-7155
Mailing Address - Fax:309-829-9512
Practice Address - Street 1:1015 E. TYLER AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-2716
Practice Address - Country:US
Practice Address - Phone:217-324-1500
Practice Address - Fax:317-324-6020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility