Organization
BEVERLY ENTERPRISES - ILLINOIS, INC.
Active
Other names
VIP Manor
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID MERRELL (VICE PRESIDENT)
(479) 201-4840
Entity
Organization
Contact information
Practice address
393 E EDWARDSVILLE RD, WOOD RIVER, IL 62095-1646
(618) 259-4111
Mailing address
393 E EDWARDSVILLE RD, WOOD RIVER, IL 62095-1646
(618) 259-4111
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
105320
BCBS
IL
01
—
47523
GROUP HP
IL
Enumeration date
10/04/2006
Last updated
08/22/2020
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