Healthcare Provider Details

I. General information

NPI: 1720073414
Provider Name (Legal Business Name): MAPLE LAWN HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N MAIN ST
EUREKA IL
61530-1085
US

IV. Provider business mailing address

700 N MAIN ST
EUREKA IL
61530-1085
US

V. Phone/Fax

Practice location:
  • Phone: 309-467-2337
  • Fax: 309-467-9011
Mailing address:
  • Phone: 309-467-2337
  • Fax: 309-467-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0042424
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1694647
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. JORDAN T POST
Title or Position: ADMINISTRATOR
Credential:
Phone: 309-467-9059