Healthcare Provider Details

I. General information

NPI: 1063659118
Provider Name (Legal Business Name): FRIENDSHIP MANOR GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S FRIENDSHIP DR
NASHVILLE IL
62263-1363
US

IV. Provider business mailing address

485 S FRIENDSHIP DR
NASHVILLE IL
62263-1363
US

V. Phone/Fax

Practice location:
  • Phone: 618-327-3041
  • Fax: 618-327-4001
Mailing address:
  • Phone: 618-327-3041
  • Fax: 618-327-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0050161
License Number StateIL

VIII. Authorized Official

Name: MRS. CATHY LIETZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-327-3041