Provider Demographics
NPI:1265413900
Name:STEPHENSON NURSING CENTER
Entity type:Organization
Organization Name:STEPHENSON NURSING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADM
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BOLT
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:815-235-6173
Mailing Address - Street 1:2946 S WALNUT RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032
Mailing Address - Country:US
Mailing Address - Phone:815-235-6173
Mailing Address - Fax:815-235-9633
Practice Address - Street 1:2946 S WALNUT RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032
Practice Address - Country:US
Practice Address - Phone:815-235-6173
Practice Address - Fax:815-235-9633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004259314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145895Medicare Oscar/Certification