Provider Demographics
NPI:1518339167
Name:PRAIRIE VILLAGE SUPPORTIVE LIVING LLC
Entity Type:Organization
Organization Name:PRAIRIE VILLAGE SUPPORTIVE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF MANAGEMENT AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEAVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-1992
Mailing Address - Street 1:200 INTERNATIONAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:RANTOUL
Mailing Address - State:IL
Mailing Address - Zip Code:61866
Mailing Address - Country:US
Mailing Address - Phone:217-892-2800
Mailing Address - Fax:217-892-2833
Practice Address - Street 1:200 INTERNATIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866
Practice Address - Country:US
Practice Address - Phone:217-892-2800
Practice Address - Fax:217-892-2833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE VILLAGE SUPPORTIVE LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-22
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)