NPI |
1609221217 |
The last name of the provider. If the provider is an individual, this is the legal name. |
Entity Type Code |
2 |
The first name of the provider, if the provider
is an individual. |
Employer Identification Number EIN |
|
The middle name of the provider, if the provider
is an individual. |
Provider Organization Name Legal Business Name |
MAS SENIOR LIVING, LLC |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Provider First Line Business Practice Location Address |
300 LERNA RD S |
Other last name by which the provider being identified is or has been known. |
Provider Business Practice Location Address City Name |
MATTOON |
Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider first name’’ if the provider is or has been known by a different last name only. |
Provider Business Practice Location Address State Name |
IL |
Other middle name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider middle name’’ if the provider
is or has been known by a different last name only. |
Provider Business Practice Location Address Postal Code |
619389389 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
2172343003 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
5/2/2016 |
The State code in the location of the provider
being identified. |
Last Update Date |
5/2/2016 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Authorized Official Last Name |
MINTON |
The country code in the location address of the provider being identified. |
Authorized Official First Name |
BLAIR |
The first name of the authorized official. |
Authorized Official Title or Position |
PRESIDENT |
The title or position of the authorized official. |
Authorized Official Telephone Number |
8155735105 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
311500000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number 1 |
0053652 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
IL |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|