NPIMap

Organization Active NPI

Prairie Village Healthcare Center Inc

  • Skilled Nursing Facility
  • Jacksonville, IL
National Provider Identifier
1356486732
Registry record updated Feb 9, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
0042671 Issued in IL
Legal business name
PRAIRIE VILLAGE HEALTHCARE CENTER INC
Practice address
1024 W Walnut St
Jacksonville, IL 62650-1251
Phone
(217) 245-5175
Fax
(217) 243-4276
NPI assigned
Feb 21, 2007
Last updated
Feb 9, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2010

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

Authorized official

Name
Jennie Shanmartin, CONTROLLER
Title
Medicare Billing
Phone
(847) 905-4026

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 0042671 IL Primary

Addresses

Primary practice location

1024 W Walnut St
Jacksonville, IL 62650-1251

Mailing address

2201 Main St
Evanston, IL 60202-1519
Phone (847) 905-4000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100517000636 IL Part A Provider - Skilled Nursing Facility 9436287174 Practice locations: Jacksonville, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356486732. Details of each certification follow.

Skilled nursing facility certification: CCN 145294

Legal name
PRAIRIE VILLAGE HEALTHCARE CENTER INC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF distinct part
Participating since
Jul 1, 1975
Last certification
May 15, 2025
Beds
126
Ownership / control type
Corporation
Organization structure
CorporationProprietary
Incorporated
Apr 17, 1997 in IL
Enrollment address
1024 W Walnut St
Jacksonville, IL 62650-1251
Nursing home name
PRAIRIE VILLAGE HEALTHCARE CTR
Affiliated entity
ATIED ASSOCIATES

Care Compare: Nursing home

Medicare Care Compare
Listed as
Prairie Village Healthcare CtrCCN 145294 · All quality measures
Overall star rating
1 of 5
Health inspections
3 of 5
Staffing
1 of 5
Quality measures
1 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Jul 1, 1975
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
12656.2 residents per day on average
Chain
Atied Associates12 facilities in the chain
Penalties (3 years)
3Fines totaling $131,684

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D0680339Prairie Village Healthcare1024 W Walnut St, Jacksonville, IL 62650Certificate of waiverAug 20, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Extended Care Clinical LLC Organization, Evanston, IL LLC Operational/Managerial Control Jan 1, 2015
Adp of the SNF Feb 13, 2025
Atied Associates LLC Organization, Evanston, IL LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Dec 31, 2020 16.67%
Adp of the SNF Dec 15, 2024
Roth & Co, LLP Organization, Evanston, IL Operational/Managerial Control Jan 1, 2015
Adp of the SNF Feb 13, 2025
Extended Care Consulting LLC Organization, Evanston, IL LLC Operational/Managerial Control Jan 1, 2015
Adp of the SNF Feb 13, 2025
Jerri Springer Individual Operational/Managerial Control Dec 1, 2015
Adp of the SNF Dec 1, 2015
Eric Rothner Individual 5% Or Greater Direct Ownership InterestOwner Dec 31, 2020 33.33%
Adp of the SNF Jan 11, 2025
William H Dixon Individual Operational/Managerial Control Jan 1, 2015
Adp of the SNF Jan 1, 2015
Sherwin Ray Individual 5% Or Greater Direct Ownership InterestOwner Dec 31, 2020 50%
Corporate OfficerPresident Jan 1, 2015
Adp of the SNF Jan 1, 2015
David Aronin Individual Corporate DirectorManager / Registered Agent Jan 1, 2015

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 42

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 42

NPI Registry JSON

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

{
    "created_epoch": "1172016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1265673600000",
    "number": "1356486732",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2201 MAIN ST",
            "city": "EVANSTON",
            "state": "IL",
            "postal_code": "602021519",
            "telephone_number": "847-905-4000",
            "fax_number": "847-905-4040"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1024 W WALNUT ST",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626501251",
            "telephone_number": "217-245-5175",
            "fax_number": "217-243-4276"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRAIRIE VILLAGE HEALTHCARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-21",
        "last_updated": "2010-02-09",
        "status": "A",
        "authorized_official_last_name": "SHANMARTIN",
        "authorized_official_first_name": "JENNIE",
        "authorized_official_title_or_position": "MEDICARE BILLING",
        "authorized_official_telephone_number": "847-905-4026",
        "authorized_official_credential": "CONTROLLER"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "0042671",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, IL

Sources for this page

Verify at the official NPI Registry.