Provider Demographics
NPI:1841599180
Name:COVENANT CARE MEADOW MANOR, LLC
Entity Type:Organization
Organization Name:COVENANT CARE MEADOW MANOR, LLC
Other - Org Name:MEADOW MANOR SKILLED NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-349-1200
Mailing Address - Street 1:800 MCADAM DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-9634
Mailing Address - Country:US
Mailing Address - Phone:217-824-2277
Mailing Address - Fax:217-287-7763
Practice Address - Street 1:800 MCADAM DR
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-9634
Practice Address - Country:US
Practice Address - Phone:217-824-2277
Practice Address - Fax:217-287-7763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11528314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
146048Medicare Oscar/Certification