Provider Demographics
NPI:1871190504
Name:THE MANOR AT JERSEYVILLE GLEN, LP
Entity Type:Organization
Organization Name:THE MANOR AT JERSEYVILLE GLEN, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-594-8581
Mailing Address - Street 1:904B ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2377
Mailing Address - Country:US
Mailing Address - Phone:618-639-9710
Mailing Address - Fax:618-639-9715
Practice Address - Street 1:904B ESTATES DR
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2377
Practice Address - Country:US
Practice Address - Phone:618-639-9710
Practice Address - Fax:618-639-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility