Healthcare Provider Details

I. General information

NPI: 1831248228
Provider Name (Legal Business Name): ILLINOIS VETERANS HOME AT MANTENO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MANTENO IL
60950-9466
US

IV. Provider business mailing address

1 VETERANS DR BLDG A-2M
MANTENO IL
60950-9466
US

V. Phone/Fax

Practice location:
  • Phone: 815-468-6581
  • Fax: 815-468-7001
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 Number0042218
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number0042218
License Number StateIL

VIII. Authorized Official

Name: REGINALD L BOOKER
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 815-468-6581