Provider Demographics
NPI:1639487408
Name:SOUTHERN ILLINOIS LIVING CENTERS INC.
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS LIVING CENTERS INC.
Other - Org Name:CLITNON MANOR LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:BRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-588-2066
Mailing Address - Street 1:300 E ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:NEW BADEN
Mailing Address - State:IL
Mailing Address - Zip Code:62265-1822
Mailing Address - Country:US
Mailing Address - Phone:618-588-2066
Mailing Address - Fax:618-588-4673
Practice Address - Street 1:111 E ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1850
Practice Address - Country:US
Practice Address - Phone:618-588-2066
Practice Address - Fax:618-588-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0033159315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371224393003Medicaid