Provider Demographics
NPI:1457348435
Name:COULTERVILLE REHABILITATION & HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:COULTERVILLE REHABILITATION & HEALTH CARE CENTER, LLC
Other - Org Name:COULTERVILLE REHABILITATION & HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-444-0900
Mailing Address - Street 1:13138 STATE ROUTE 13
Mailing Address - Street 2:
Mailing Address - City:COULTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62237-1134
Mailing Address - Country:US
Mailing Address - Phone:618-758-2256
Mailing Address - Fax:618-758-3506
Practice Address - Street 1:13138 STATE ROUTE 13
Practice Address - Street 2:
Practice Address - City:COULTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62237-1134
Practice Address - Country:US
Practice Address - Phone:618-758-2256
Practice Address - Fax:618-758-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0042820314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3641375870001Medicaid
IL364137587001Medicaid
IL3641375870001Medicaid