Organization
EVERGREEN GLENHAVEN OPERATIONS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID UNDERWOOD (EXEC VP & CFO)
(309) 823-7135
Entity
Organization
Contact information
Practice address
100 GLENHAVEN DR, ALTON, IL 62002-6700
(618) 462-1500
Mailing address
115 W JEFFERSON ST., SUITE 401, BLOOMINGTON, IL 61701
(309) 828-4361
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
3522842186220201
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
352284218001
—
IL
Enumeration date
10/06/2008
Last updated
05/18/2016
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