Provider Demographics
NPI:1629247283
Name:MCLEAN COUNTY ASSISTED LIVING, L.L.C.
Entity Type:Organization
Organization Name:MCLEAN COUNTY ASSISTED LIVING, L.L.C.
Other - Org Name:EVERGREEN VILLAGE SUPPORTIVE LIVING, L.L.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR V. P. OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:115 W JEFFERSON ST
Mailing Address - Street 2:SUITE 401, PO BOX 3188
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3946
Mailing Address - Country:US
Mailing Address - Phone:309-823-7155
Mailing Address - Fax:309-829-9512
Practice Address - Street 1:1701 EVERGREEN VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-452-7300
Practice Address - Fax:309-452-7311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEAN COUNTY ASSISTED LIVING, L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-27
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205051684001Medicaid