Provider Demographics
NPI:1497889554
Name:COUNTY OF FULTON
Entity Type:Organization
Organization Name:COUNTY OF FULTON
Other - Org Name:THE CLAYBERG FULTON COUNTY NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DANIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:309-785-5012
Mailing Address - Street 1:PO BOX 200
Mailing Address - Street 2:625 EAST MONROE STREET
Mailing Address - City:CUBA
Mailing Address - State:IL
Mailing Address - Zip Code:61427-0200
Mailing Address - Country:US
Mailing Address - Phone:309-785-5012
Mailing Address - Fax:309-785-5376
Practice Address - Street 1:625 EAST MONROE STREET
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:IL
Practice Address - Zip Code:61427-0200
Practice Address - Country:US
Practice Address - Phone:309-785-5012
Practice Address - Fax:309-785-5376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0014290313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370914241001Medicaid