| Organization Name: | PRAIRIE VILLAGE SUPPORTIVE LIVING LLC |
| NPI Number: | 1518339167 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOELLEN BLEAVINS (VICE PRESIDENT OF MANAGEMENT AGENT) |
| Mailing Address: | 200 International Drive Rantoul |
| State: | IL US |
| Postal Code: | 61866 |
| Phone Number: | 2178922800 |
| Fax Number: | 2178922833 |
| NPI Enumeration Date: | 10/22/2015 |
| NPI Last Update Date: | 11/03/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 311500000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Nursing & Custodial Care Facilities |
| Taxonomy Classification: | Alzheimer Center (Dementia Center) |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A freestanding facility or special care unit of a long term care facility focusing on patient care of individuals diagnosed with dementia or Alzheimer |