Provider Demographics
NPI:1649268947
Name:PALLADIAN TAYLORVILLE SNF LLC
Entity type:Organization
Organization Name:PALLADIAN TAYLORVILLE SNF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-566-0459
Mailing Address - Street 1:1670 ESSEX WAY STE B
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3063
Mailing Address - Country:US
Mailing Address - Phone:618-327-3064
Mailing Address - Fax:618-327-3083
Practice Address - Street 1:600 S HOUSTON ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2073
Practice Address - Country:US
Practice Address - Phone:217-824-9636
Practice Address - Fax:217-824-8437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1615453314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3711606626256801Medicaid
IL=========6256801Medicaid