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General NPI Number Information
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NPI Number | 1134126063
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Entity Type | Organization
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Legal Business Name | DECATUR MANOR HEALTHCARE, LLC
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Dates
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Enumeration Date | 07/07/2005
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Last Update Date | 09/09/2013
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Provider Practice Location Address
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Address Line | 1016 W PERSHING RD
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City | DECATUR
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State | IL
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Zip | 62526-1541
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Country | US
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Telephone | 217-875-0833
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Fax | 217-875-6851
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Provider Business Mailing Address
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Address Line | 6840 N LINCOLN AVE
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City | LINCOLNWOOD
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State | IL
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Zip | 60712-2628
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Country | US
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Telephone | 847-675-7979
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Fax | 847-675-0555
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Authorized Official
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Title or Position | CFO
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Name | MR. THOMAS WINTER
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Credential | CPA
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Telephone | 847-675-7979
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310500000X
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Taxonomy Name | Mental Illness Intermediate Care Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 310500000X
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Taxonomy Name | Mental Illness Intermediate Care Facility
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License Number | 0049262
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License Number State | IL
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