Provider Demographics
NPI:1184774465
Name:GREENBRIER LODGE, INC.
Entity type:Organization
Organization Name:GREENBRIER LODGE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR V.P. OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-4361
Mailing Address - Street 1:600 S. MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:PIPER CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60959
Mailing Address - Country:US
Mailing Address - Phone:815-686-2277
Mailing Address - Fax:815-686-2812
Practice Address - Street 1:600 S. MAPLE STREET
Practice Address - Street 2:
Practice Address - City:PIPER CITY
Practice Address - State:IL
Practice Address - Zip Code:60959
Practice Address - Country:US
Practice Address - Phone:815-686-2277
Practice Address - Fax:815-686-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0044487314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid