Provider Demographics
NPI:1891456216
Name:IMBODEN CREEK GARDENS LLC
Entity Type:Organization
Organization Name:IMBODEN CREEK GARDENS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:618-294-8696
Mailing Address - Street 1:215 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-1504
Mailing Address - Country:US
Mailing Address - Phone:618-294-8696
Mailing Address - Fax:618-294-8699
Practice Address - Street 1:185 W IMBODEN DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5251
Practice Address - Country:US
Practice Address - Phone:217-233-1425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-07
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility