Provider Demographics
NPI:1831138890
Name:ELMWOOD NURSING & REHABILITATION CENTER, L.L.C.
Entity Type:Organization
Organization Name:ELMWOOD NURSING & REHABILITATION CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAKHLOUF
Authorized Official - Middle Name:
Authorized Official - Last Name:SUISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-344-7750
Mailing Address - Street 1:152 WILMA DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5435
Mailing Address - Country:US
Mailing Address - Phone:618-344-7750
Mailing Address - Fax:618-344-3520
Practice Address - Street 1:152 WILMA DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5435
Practice Address - Country:US
Practice Address - Phone:618-344-7750
Practice Address - Fax:618-344-3520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0041210314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid
IL1313990001Medicare NSC