Organization
BEVERLY ENTERPRISES - ILLINOIS, INC.
Active
Other names
Blu Fountain Manor
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID MERRELL (VICE PRESIDENT)
(479) 201-4840
Entity
Organization
Contact information
Practice address
1623 W. DELMAR, #29, GODFREY, IL 62035
(618) 466-0443
Mailing address
1623 W. DELMAR, #29, GODFREY, IL 62035
(618) 466-0443
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
105286
BCBS
IL
01
—
53511
GROUP HP
IL
Enumeration date
10/02/2006
Last updated
08/22/2020
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