Provider Demographics
NPI:1427186451
Name:STONEBRIDGE SENIOR LIVING CENTER, LLC
Entity Type:Organization
Organization Name:STONEBRIDGE SENIOR LIVING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-713-5284
Mailing Address - Street 1:902 S MCLEANSBORO ST
Mailing Address - Street 2:PO BOX 968
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-3413
Mailing Address - Country:US
Mailing Address - Phone:618-439-4501
Mailing Address - Fax:618-435-3141
Practice Address - Street 1:902 S MCLEANSBORO ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-3413
Practice Address - Country:US
Practice Address - Phone:618-439-4501
Practice Address - Fax:618-435-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0051888314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid