Healthcare Provider Details

I. General information

NPI: 1558309138
Provider Name (Legal Business Name): HEARTLAND OF NORMAL IL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BROADWAY ST
NORMAL IL
61761-3762
US

IV. Provider business mailing address

333 N SUMMIT ST
TOLEDO OH
43604-2615
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-4406
  • Fax: 309-454-7908
Mailing address:
  • Phone: 419-252-5500
  • Fax: 877-385-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0027532
License Number StateIL

VIII. Authorized Official

Name: MR. MARTIN D ALLEN
Title or Position: DIRECTOR
Credential:
Phone: 419-252-5734