Evergreen Glenhaven Operations, LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

3522842186220201 Issued in IL

Legal business name

EVERGREEN GLENHAVEN OPERATIONS, LLC

Practice address

100 Glenhaven Dr
Alton, IL 62002-6700

Phone

(618) 462-1500

NPI assigned

Oct 6, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

David Underwood

Title

Exec VP & Cfo

Phone

(309) 823-7135

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1223251200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1463529600000",
    "number": "1013168202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 W JEFFERSON ST.",
            "address_2": "SUITE 401",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "61701",
            "telephone_number": "309-828-4361"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 GLENHAVEN DR",
            "city": "ALTON",
            "state": "IL",
            "postal_code": "620026700",
            "telephone_number": "618-462-1500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN GLENHAVEN OPERATIONS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-06",
        "last_updated": "2016-05-18",
        "status": "A",
        "authorized_official_last_name": "UNDERWOOD",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "EXEC VP & CFO",
        "authorized_official_telephone_number": "309-823-7135"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "IL",
            "license": "3522842186220201",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "352284218001",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Christina Endicott
• Samuel J Essma, MD
• Jacqueline Estrada, CRNA
• Roy M. Evans, L.C.S.W.
• Stephanie Evans
• Kaycee Eyers, FNP
• Christina Faccin, D.C.
• Amy Elizabeth Fahnestock
• Fairview Heights Medical Group SC
• Fairview Heights Medical Group SC

• Assisted Living Facility in Alton, IL
• Providers in Alton, IL by specialty
• Assisted Living Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 18, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.