Healthcare Provider Details

I. General information

NPI: 1700819778
Provider Name (Legal Business Name): LTC OF ILLINOIS - FIRESIDE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 MARTIN LUTHER KING DR
CENTRALIA IL
62801-3002
US

IV. Provider business mailing address

1030 MARTIN LUTHER KING DR
CENTRALIA IL
62801-3002
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-1833
  • Fax: 618-532-1308
Mailing address:
  • Phone: 618-532-1833
  • Fax: 618-532-1308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0045690
License Number StateIL

VIII. Authorized Official

Name: DOUGLAS K MITTLEIDER
Title or Position: PRESIDENT
Credential:
Phone: 770-619-0866