=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013272285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HELIA HEALTHCARE OF BENTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2012
-----------------------------------------------------
Last Update Date | 07/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1310 MARK FRANKLIN DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62812-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-439-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1310 MARK FRANKLIN DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62812-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-439-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF ACCOUNTS RECEIVABLE
-----------------------------------------------------
Name | THERESA CONROY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-431-0511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 005231
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------