Provider Demographics
NPI:1932109485
Name:CARAVILLA RESIDENTIAL CENTERS, INC
Entity Type:Organization
Organization Name:CARAVILLA RESIDENTIAL CENTERS, INC
Other - Org Name:JEFFERSONIAN HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RECEIVER FOR, CORPORTATE ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:FLANAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-444-0900
Mailing Address - Street 1:1700 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-4349
Mailing Address - Country:US
Mailing Address - Phone:618-242-4075
Mailing Address - Fax:618-242-4092
Practice Address - Street 1:1700 WHITE ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-4349
Practice Address - Country:US
Practice Address - Phone:618-242-4075
Practice Address - Fax:618-242-4092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0039818314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid
IL145517AMedicare ID - Type UnspecifiedMEDICARE