Provider Demographics
NPI:1679779045
Name:CARBONDALE SLF, LP
Entity type:Organization
Organization Name:CARBONDALE SLF, LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-351-7955
Mailing Address - Street 1:955 VILLA CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-6001
Mailing Address - Country:US
Mailing Address - Phone:618-351-7955
Mailing Address - Fax:618-351-6955
Practice Address - Street 1:955 VILLA CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-6001
Practice Address - Country:US
Practice Address - Phone:618-351-7955
Practice Address - Fax:618-351-6955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCERTIFICATION310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid