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General NPI Number Information
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NPI Number | 1366447617
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Entity Type | Organization
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Legal Business Name | IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
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Dates
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Enumeration Date | 06/14/2005
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 200 E FAIRMAN AVE
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City | WATSEKA
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State | IL
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Zip | 60970-1644
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Country | US
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Telephone | 815-432-6175
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Fax | 815-432-6199
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Provider Business Mailing Address
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Address Line | 200 LAIRD LN
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City | WATSEKA
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State | IL
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Zip | 60970-7568
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Country | US
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Telephone | 815-432-6175
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Fax | 815-432-6199
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Authorized Official
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Title or Position | CEO
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Name | MICHAEL TILSTRA
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Credential |
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Telephone | 815-432-7777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 1006881
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License Number State | IL
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