Provider Demographics
NPI:1558343301
Name:ST. MARYS HEALTH CARE CENTER INVESTORS LLC
Entity Type:Organization
Organization Name:ST. MARYS HEALTH CARE CENTER INVESTORS LLC
Other - Org Name:EDWARDSVILLE NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-692-1330
Mailing Address - Street 1:401 SAINT MARYS DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-4276
Mailing Address - Country:US
Mailing Address - Phone:618-692-1330
Mailing Address - Fax:618-692-9478
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:618-692-9478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1558343301OtherNPI
IL=========Medicaid
IL=========Medicaid