Provider Demographics
NPI:1447284245
Name:LAKEWOOD SENIOR LIVING OF MATTOON
Entity type:Organization
Organization Name:LAKEWOOD SENIOR LIVING OF MATTOON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-320-7575
Mailing Address - Street 1:2121 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MATTON
Mailing Address - State:IL
Mailing Address - Zip Code:61938
Mailing Address - Country:US
Mailing Address - Phone:217-235-7138
Mailing Address - Fax:217-235-7140
Practice Address - Street 1:2121 S 9TH ST
Practice Address - Street 2:
Practice Address - City:MATTON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-235-7138
Practice Address - Fax:217-235-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0041574314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145480Medicare ID - Type Unspecified