Healthcare Provider Details

I. General information

NPI: 1588655476
Provider Name (Legal Business Name): HERITAGE MANOR - MT. ZION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 WOODLAND DR
MT ZION IL
62549-1237
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 217-864-2356
  • Fax: 217-864-4960
Mailing address:
  • Phone: 309-828-4361
  • Fax: 309-829-9512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number48074
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number0048074
License Number StateIL

VIII. Authorized Official

Name: MR. DAVID M UNDERWOOD
Title or Position: SR. VP & CFO
Credential:
Phone: 309-828-4361