14D2213849 CLIA NUMBER - JERSEYVILLE ESTATES MANOR AT JERSEYVILLE GLEN, THE

Laboratory Demographics

CLIA Number: 14D2213849

Facility Name: JERSEYVILLE ESTATES MANOR AT JERSEYVILLE GLEN, THE

Facility Address:
1210 E FAIRGROUNDS AVE
JERSEYVILLE, IL
ZIP 62052
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Facility Phone Number: 618 639-9700

Facility Type: Other - SUPPORTIVE LIVING

Certificate Type: Waiver

NPI Number: 1336428937

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	14D2213849
LAB Type	Other - SUPPORTIVE LIVING
Facility Name	JERSEYVILLE ESTATES MANOR AT JERSEYVILLE GLEN, THE
Street	1210 E FAIRGROUNDS AVE
City	JERSEYVILLE
State	IL
ZIP	62052
Phone	618 639-9700
CertificateType	4
CertificateEffectiveDate	2/17/2023
CertificateExpirationDate	2/16/2025
FacilityType	Waiver

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