- Enrollment id
- O20190206000066
- Enrollment state
- IL
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1861963217
- Multiple npi flag
- N
- Ccn
- 145879
- Associate id
- 9638417314
- Organization name
- TRI-STATE VILLAGE NURSING AND REHABILITATION CENTER LLC
- Doing business as name
- TRI-STATE VILLAGE NURSING AND REHABILITATION CENTER
- Incorporation date
- 1995-09-01
- Incorporation state
- IL
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- TRI-STATE VILLAGE NRSG & RHB
- Affiliation entity name
- ATIED ASSOCIATES
- Affiliation entity id
- 53
- Address line 1
- 2500 175TH ST
- City
- LANSING
- State
- IL
- Zip code
- 604381801