Provider Demographics
NPI:1487852083
Name:BONAN BROTHERS PROPERTIES PROJECT #2, LLC
Entity Type:Organization
Organization Name:BONAN BROTHERS PROPERTIES PROJECT #2, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:IOERGER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:618-533-5278
Mailing Address - Street 1:2047 E MCCORD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-6782
Mailing Address - Country:US
Mailing Address - Phone:618-533-5278
Mailing Address - Fax:618-533-4406
Practice Address - Street 1:2047 E MCCORD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-6782
Practice Address - Country:US
Practice Address - Phone:618-533-5278
Practice Address - Fax:618-533-4406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid