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General NPI Number Information
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NPI Number | 1972709657
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Entity Type | Organization
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Legal Business Name | HERITAGE WOODS OF BENTON
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1305 BAILEY LN
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City | BENTON
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State | IL
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Zip | 62812-2861
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Country | US
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Telephone | 618-439-9431
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Fax |
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Provider Business Mailing Address
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Address Line | 1305 BAILEY LN
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City | BENTON
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State | IL
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Zip | 62812-2861
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Country | US
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Telephone | 618-439-9431
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. SUSAN R. COLONI
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Credential |
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Telephone | 618-439-9431
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State | IL
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