Provider Demographics
NPI:1174518278
Name:SOUTHERN ILLINOIS LIVING CENTERS INC.
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS LIVING CENTERS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:618-588-2066
Mailing Address - Street 1:111 E ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:NEW BADEN
Mailing Address - State:IL
Mailing Address - Zip Code:62265-1850
Mailing Address - Country:US
Mailing Address - Phone:618-588-2066
Mailing Address - Fax:618-588-4673
Practice Address - Street 1:111 E ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1850
Practice Address - Country:US
Practice Address - Phone:618-588-4924
Practice Address - Fax:618-588-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0033159315P00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0033159OtherIDPH LICENSE NUMBER
IL=========003Medicaid
IL0033159OtherIDPH LICENSE NUMBER
IL=========001Medicaid
IL=========002Medicaid