14D2194739 CLIA NUMBER - EVERGREEN PLACE

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Laboratory Demographics

CLIA Number: 14D2194739

Facility Name: EVERGREEN PLACE

Facility Address:
1529 E MAIN
STREATOR, IL
ZIP 61364
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Facility Phone Number: 815 672-0903

Facility Type: Other - SUPPORTIVE LIVING FAC

Certificate Type: Waiver

NPI Number: 1295980852

Taxonomy: 310400000X - Assisted Living Facility
A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being.

CLIA Record

Field Name	Field Value
CLIA Number	14D2194739
LAB Type	Other - SUPPORTIVE LIVING FAC
Facility Name	EVERGREEN PLACE
Street	1529 E MAIN
City	STREATOR
State	IL
ZIP	61364
Phone	815 672-0903
CertificateType	4
CertificateEffectiveDate	10/2/2022
CertificateExpirationDate	10/1/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024