Provider Demographics
NPI:1013124593
Name:ADELINE E. PROUTY TRUST
Entity type:Organization
Organization Name:ADELINE E. PROUTY TRUST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:KAUFMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-872-2261
Mailing Address - Street 1:508 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-2538
Mailing Address - Country:US
Mailing Address - Phone:815-872-2261
Mailing Address - Fax:815-875-1758
Practice Address - Street 1:508 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2538
Practice Address - Country:US
Practice Address - Phone:815-872-2261
Practice Address - Fax:815-875-1758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0021956310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility