Provider Demographics
NPI:1255767166
Name:LAVENDER RIDGE INC
Entity type:Organization
Organization Name:LAVENDER RIDGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-342-4150
Mailing Address - Street 1:1103 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1793
Mailing Address - Country:US
Mailing Address - Phone:217-342-4150
Mailing Address - Fax:217-342-4199
Practice Address - Street 1:1103 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1793
Practice Address - Country:US
Practice Address - Phone:217-342-4150
Practice Address - Fax:217-342-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)