Provider Demographics
NPI:1881015329
Name:ST CLAIR SUPPORTIVE LIVING LP
Entity type:Organization
Organization Name:ST CLAIR SUPPORTIVE LIVING LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, KNOLLWOOD MANAGEMENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-394-0569
Mailing Address - Street 1:921 KNOLLWOOD VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:CASEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62232-1808
Mailing Address - Country:US
Mailing Address - Phone:618-394-0569
Mailing Address - Fax:618-394-0582
Practice Address - Street 1:921 KNOLLWOOD VILLAGE RD
Practice Address - Street 2:
Practice Address - City:CASEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62232-1808
Practice Address - Country:US
Practice Address - Phone:618-394-0569
Practice Address - Fax:618-394-0582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL311ZA0620X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid