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General NPI Number Information
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NPI Number | 1861483307
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Entity Type | Organization
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Legal Business Name | HERITAGE MANOR - WALNUT, LLC
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Dates
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Enumeration Date | 11/03/2005
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Last Update Date | 01/12/2016
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Provider Practice Location Address
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Address Line | 308 S 2ND ST
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City | WALNUT
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State | IL
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Zip | 61376-9363
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Country | US
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Telephone | 815-379-2131
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Fax | 815-379-2235
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Provider Business Mailing Address
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Address Line | 115 W JEFFERSON ST SUITE 401
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City | BLOOMINGTON
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State | IL
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Zip | 61701-3946
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Country | US
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Telephone | 309-828-4361
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Fax | 309-829-5477
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Authorized Official
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Title or Position | SR. VP & CFO
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Name | MR. DAVID M UNDERWOOD
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Credential |
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Telephone | 309-823-7135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 0015784
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License Number State | IL
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