Healthcare Provider Details

I. General information

NPI: 1386708568
Provider Name (Legal Business Name): ILLINOIS VETERANS HOME AT QUINCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 N 12TH ST
QUINCY IL
62301-1355
US

IV. Provider business mailing address

1707 N 12TH ST BLDG 29M
QUINCY IL
62301-1355
US

V. Phone/Fax

Practice location:
  • Phone: 217-222-8641
  • Fax: 217-222-8578
Mailing address:
  • Phone: 217-222-9487
  • Fax: 217-222-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0044107
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number44107
License Number StateIL

VIII. Authorized Official

Name: BRUCE L VACA
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 217-222-8641