=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669672465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE WOODS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 WEST 4TH STREET
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-662-4599
-----------------------------------------------------
Fax | 618-662-6179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1003 WEST 4TH STREET
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-662-4599
-----------------------------------------------------
Fax | 618-662-6179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. DEBORAH MICHELE ARTIS
-----------------------------------------------------
Credential | MS LCPC
-----------------------------------------------------
Telephone | 618-662-4599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------