Healthcare Provider Details

I. General information

NPI: 1942367453
Provider Name (Legal Business Name): ILLINOIS VETERANS HOME AT LASALLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 OCONOR AVE
LA SALLE IL
61301-1216
US

IV. Provider business mailing address

1015 OCONOR AVE
LA SALLE IL
61301-1216
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-0303
  • Fax: 815-223-5815
Mailing address:
  • Phone: 217-222-9487
  • Fax: 217-222-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number44115
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number44115
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JOHN G. KOEHLER
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 815-223-0303