- Enrollment id
- O20100517000636
- Enrollment state
- IL
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1356486732
- Multiple npi flag
- N
- Ccn
- 145294
- Associate id
- 9436287174
- Organization name
- PRAIRIE VILLAGE HEALTHCARE CENTER INC
- Incorporation date
- 1997-04-17
- Incorporation state
- IL
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Nursing home provider name
- PRAIRIE VILLAGE HEALTHCARE CTR
- Affiliation entity name
- ATIED ASSOCIATES
- Affiliation entity id
- 53
- Address line 1
- 1024 W WALNUT ST
- City
- JACKSONVILLE
- State
- IL
- Zip code
- 626501251