Healthcare Provider Details

I. General information

NPI: 1679865455
Provider Name (Legal Business Name): HERITAGE MANOR LASALLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 CHARTRES ST
LA SALLE IL
61301-1508
US

IV. Provider business mailing address

1445 CHARTRES ST
LA SALLE IL
61301-1508
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-4700
  • Fax: 815-223-4708
Mailing address:
  • Phone: 815-223-4700
  • Fax: 815-223-4708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0051276
License Number StateIL

VIII. Authorized Official

Name: MR. DAVID M UNDERWOOD
Title or Position: SR VP & CFO
Credential:
Phone: 309-823-7135