Provider Demographics
NPI:1902229537
Name:PINCKNEYVILLE NURSING & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:PINCKNEYVILLE NURSING & REHABILITATION CENTER, LLC
Other - Org Name:PINCKNEYVILLE NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
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:618-252-6383
Mailing Address - Street 1:708 VIRGINIA CT
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-1538
Mailing Address - Country:US
Mailing Address - Phone:618-357-2493
Mailing Address - Fax:618-357-3120
Practice Address - Street 1:708 VIRGINIA CT
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1538
Practice Address - Country:US
Practice Address - Phone:618-357-2493
Practice Address - Fax:618-357-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0052704314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0052704OtherILLINOIS DEPARTMENT OF PUBLIC HEALTH LICENSE NUMBER
146175Medicare Oscar/Certification