Provider Demographics
NPI:1184894412
Name:PARENTS AND FRIENDS OF THE SLC-HOME 1
Entity type:Organization
Organization Name:PARENTS AND FRIENDS OF THE SLC-HOME 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:K
Authorized Official - Last Name:KEIGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-277-7730
Mailing Address - Street 1:3 GUNDLACH PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-4227
Mailing Address - Country:US
Mailing Address - Phone:618-277-7730
Mailing Address - Fax:618-277-5423
Practice Address - Street 1:3 GUNDLACH PL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-4227
Practice Address - Country:US
Practice Address - Phone:618-277-7730
Practice Address - Fax:618-277-5423
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARENTS AND FRIENDS OF THE SPECIALIZED LIVING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL6012769313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6012769Medicaid