Healthcare Provider Details

I. General information

NPI: 1831194752
Provider Name (Legal Business Name): MEADOWS MENNONITE RETIREMENT COMMUNITY ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24588 CHURCH ST
CHENOA IL
61726-9395
US

IV. Provider business mailing address

24588 CHURCH ST
CHENOA IL
61726-9395
US

V. Phone/Fax

Practice location:
  • Phone: 309-747-2702
  • Fax: 309-747-2944
Mailing address:
  • Phone: 309-747-2702
  • Fax: 309-747-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number0011544
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number0011544
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0011544
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0011544
License Number StateIL

VIII. Authorized Official

Name: MR. ROBERT O. BERTSCHE
Title or Position: ADMINISTRATOR CEO
Credential:
Phone: 309-747-2702