Provider Demographics
NPI:1518475524
Name:EDWARDSVILLE CARE CENTER, LLC
Entity Type:Organization
Organization Name:EDWARDSVILLE CARE CENTER, LLC
Other - Org Name:EDWARDSVILLE NURSING & REHABILIATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/MEMBER OF LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:MAKHLOUF
Authorized Official - Middle Name:
Authorized Official - Last Name:SUISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-744-8688
Mailing Address - Street 1:1401 S BRENTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1437
Mailing Address - Country:US
Mailing Address - Phone:314-963-7570
Mailing Address - Fax:314-963-9030
Practice Address - Street 1:401 SAINT MARYS DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-4276
Practice Address - Country:US
Practice Address - Phone:618-692-1330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility