Healthcare Provider Details

I. General information

NPI: 1801130513
Provider Name (Legal Business Name): HERITAGE MANOR - GILLESPIE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7588 STAUNTON RD
GILLESPIE IL
62033-3232
US

IV. Provider business mailing address

115 W JEFFERSON ST SUITE 401
BLOOMINGTON IL
61701-3946
US

V. Phone/Fax

Practice location:
  • Phone: 217-839-2171
  • Fax: 217-839-1372
Mailing address:
  • Phone: 309-828-4361
  • Fax: 309-829-5477

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 UNDERWOOD
Title or Position: EXEC VP, CFO
Credential: CPA
Phone: 309-823-7135