Provider Demographics
NPI:1689856312
Name:PEKIN SUPPORTIVE LIVING LIMITED PATNERSHIP
Entity Type:Organization
Organization Name:PEKIN SUPPORTIVE LIVING LIMITED PATNERSHIP
Other - Org Name:JOHN M EVANS SLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-477-8800
Mailing Address - Street 1:1320 EXECUTIVE COURT
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554
Mailing Address - Country:US
Mailing Address - Phone:309-477-8800
Mailing Address - Fax:309-477-8801
Practice Address - Street 1:1320 EXECUTIVE COURT
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554
Practice Address - Country:US
Practice Address - Phone:309-477-8800
Practice Address - Fax:309-477-8801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LABORERES HOME VII
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility