Provider Demographics
NPI:1053392894
Name:COLUMBIA CONVALESCENT CENTER
Entity type:Organization
Organization Name:COLUMBIA CONVALESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:WENDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-281-6800
Mailing Address - Street 1:253 BRADINGTON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2519
Mailing Address - Country:US
Mailing Address - Phone:618-281-6800
Mailing Address - Fax:618-281-6557
Practice Address - Street 1:253 BRADINGTON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2519
Practice Address - Country:US
Practice Address - Phone:618-281-6800
Practice Address - Fax:618-281-6557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0037556314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145717Medicare ID - Type Unspecified