Healthcare Provider Details

I. General information

NPI: 1083609960
Provider Name (Legal Business Name): BRETHREN HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 S WESLEY AVE
MOUNT MORRIS IL
61054-1428
US

IV. Provider business mailing address

414 S WESLEY AVE
MOUNT MORRIS IL
61054-1428
US

V. Phone/Fax

Practice location:
  • Phone: 815-734-4103
  • Fax: 815-734-7318
Mailing address:
  • Phone: 815-734-4103
  • Fax: 815-734-7318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1676853
License Number StateIL

VIII. Authorized Official

Name: MS. FEROL J. LABASH
Title or Position: CEO
Credential: NHA
Phone: 815-734-4103