Healthcare Provider Details

I. General information

NPI: 1164646550
Provider Name (Legal Business Name): MULBERRY MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 E DAVIE
ANNA IL
62906-0088
US

IV. Provider business mailing address

PO BOX 88
ANNA IL
62906-0088
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-6012
  • Fax:
Mailing address:
  • Phone: 618-833-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateIL

VIII. Authorized Official

Name: JOANN KELLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-833-6012