1629069331 NPI number — HERITAGE MANOR STAUNTON LLC

Table of content: (NPI 1629069331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629069331 NPI number — HERITAGE MANOR STAUNTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE MANOR STAUNTON LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HERITAGE HEALTH - STAUNTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629069331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 W JEFFERSON ST
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61701-3946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-828-4361
Provider Business Mailing Address Fax Number:
309-829-9512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 W PENNSYLVANIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAUNTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62088-1127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-635-5577
Provider Business Practice Location Address Fax Number:
618-635-5580
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
UNDERWOOD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SR. VP & CFO
Authorized Official Telephone Number:
309-828-4361

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0048876 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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