Healthcare Provider Details

I. General information

NPI: 1275764466
Provider Name (Legal Business Name): NORTH LOGAN HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N LOGAN AVE
DANVILLE IL
61832-3715
US

IV. Provider business mailing address

801 N LOGAN AVE
DANVILLE IL
61832-3715
US

V. Phone/Fax

Practice location:
  • Phone: 217-443-3106
  • Fax: 217-443-3187
Mailing address:
  • Phone: 217-443-3106
  • Fax: 217-443-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0046532
License Number StateIL

VIII. Authorized Official

Name: MRS. CLAIRE JANE MATHENY
Title or Position: ADMINISTRATOR
Credential: ADMINISTATOR
Phone: 217-443-3106