Healthcare Provider Details

I. General information

NPI: 1376014969
Provider Name (Legal Business Name): HERITAGE MANOR CHILLICOTHE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2018
Last Update Date: 12/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 W HILLCREST DR
CHILLICOTHEE IL
61523-2258
US

IV. Provider business mailing address

115 W JEFFERSON ST STE 401
BLOOMINGTON IL
61701-3967
US

V. Phone/Fax

Practice location:
  • Phone: 309-274-2194
  • Fax:
Mailing address:
  • Phone: 309-828-4361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: DAVID M UNDERWOOD
Title or Position: CFO
Credential:
Phone: 309-828-4361