Healthcare Provider Details

I. General information

NPI: 1992894802
Provider Name (Legal Business Name): IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E FAIRMAN AVENUE
WATSEKA IL
60970-1644
US

IV. Provider business mailing address

200 E FAIRMAN AVENUE
WATSEKA IL
60970-1644
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-5841
  • Fax: 815-432-7821
Mailing address:
  • Phone: 815-432-5841
  • Fax: 815-432-7821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0014464
License Number StateIL

VIII. Authorized Official

Name: TIMOTHY L SMITH
Title or Position: COO
Credential:
Phone: 815-432-7967