Provider Demographics
NPI:1427405075
Name:IMBODEN CREEK LIVING CENTERS
Entity Type:Organization
Organization Name:IMBODEN CREEK LIVING CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICARE BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLEY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BAITY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-422-7150
Mailing Address - Street 1:180 W IMBODEN DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5238
Mailing Address - Country:US
Mailing Address - Phone:217-422-7150
Mailing Address - Fax:217-422-9418
Practice Address - Street 1:180 W IMBODEN DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5238
Practice Address - Country:US
Practice Address - Phone:217-422-7150
Practice Address - Fax:217-422-9418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========802Medicaid