Healthcare Provider Details

I. General information

NPI: 1518948280
Provider Name (Legal Business Name): ASTA CARE CENTER OF BLOOMINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 N CALHOUN
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

1509 N CALHOUN
BLOOMINGTON IL
61704
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-6046
  • Fax: 309-829-1992
Mailing address:
  • Phone: 309-827-6046
  • Fax: 309-829-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0042283
License Number StateIL

VIII. Authorized Official

Name: SETH GILLMAN
Title or Position: MEMBER
Credential:
Phone: 309-827-6046