Provider Demographics
NPI:1851793285
Name:TIMBERLAKE ESTATES SLF, LP
Entity Type:Organization
Organization Name:TIMBERLAKE ESTATES SLF, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICARE BILLING FACILITATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-732-5119
Mailing Address - Street 1:2521 EMPOWERMENT RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-4983
Mailing Address - Country:US
Mailing Address - Phone:217-321-2100
Mailing Address - Fax:217-321-2130
Practice Address - Street 1:2521 EMPOWERMENT RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4983
Practice Address - Country:US
Practice Address - Phone:217-321-2100
Practice Address - Fax:217-321-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205917599001Medicaid