Provider Demographics
NPI:1568655801
Name:WOOD RIVER RETIREMENT CENTER, INC
Entity Type:Organization
Organization Name:WOOD RIVER RETIREMENT CENTER, INC
Other - Org Name:FOXES GROVE SUPPORTIVE LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-994-9070
Mailing Address - Street 1:11701 BORMAN DR STE 315
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4194
Mailing Address - Country:US
Mailing Address - Phone:314-994-9070
Mailing Address - Fax:
Practice Address - Street 1:395 E EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1600
Practice Address - Country:US
Practice Address - Phone:618-259-0851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL9999999310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid