Provider Demographics
NPI:1609221217
Name:MAS SENIOR LIVING, LLC
Entity Type:Organization
Organization Name:MAS SENIOR LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MINTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-573-5105
Mailing Address - Street 1:556 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4906
Mailing Address - Country:US
Mailing Address - Phone:815-573-5105
Mailing Address - Fax:
Practice Address - Street 1:300 LERNA RD S
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9389
Practice Address - Country:US
Practice Address - Phone:217-234-3003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0053652311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)