Healthcare Provider Details

I. General information

NPI: 1861483307
Provider Name (Legal Business Name): HERITAGE MANOR - WALNUT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 S 2ND ST
WALNUT IL
61376-9363
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 815-379-2131
  • Fax: 815-379-2235
Mailing address:
  • Phone: 309-828-4361
  • Fax: 309-829-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0015784
License Number StateIL

VIII. Authorized Official

Name: MR. DAVID M UNDERWOOD
Title or Position: SR. VP & CFO
Credential:
Phone: 309-823-7135