Healthcare Provider Details

I. General information

NPI: 1487645024
Provider Name (Legal Business Name): MASON CITY AREA NURSING HOME ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N PRICE ST
MASON CITY IL
62664-9600
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 217-482-5022
  • Fax: 217-482-3220
Mailing address:
  • Phone: 309-828-4361
  • Fax: 309-829-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0034256
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number034256
License Number StateIL

VIII. Authorized Official

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