Provider Demographics
NPI:1104945716
Name:LEBANON TERRACE
Entity type:Organization
Organization Name:LEBANON TERRACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QMRP
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-537-4133
Mailing Address - Street 1:221 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1668
Mailing Address - Country:US
Mailing Address - Phone:618-537-4133
Mailing Address - Fax:618-537-4156
Practice Address - Street 1:221 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1668
Practice Address - Country:US
Practice Address - Phone:618-537-4133
Practice Address - Fax:618-537-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038430320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid