MEDICARE: HERITAGE MANOR - EL PASO, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BX2000X	Oxygen Equipment & Supplies (DME)	0048124	IL
2	314000000X	Skilled Nursing Facility	48124	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093706137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE MANOR - EL PASO, LLC

Provider Business Mailing Address
First Line	:	115 W JEFFERSON ST
Second Line	:	SUITE 401
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-3946
Country	:	US
Telephone Number	:	309-828-4361
Fax Number	:	309-829-9512

Provider Business Practice Location Address
First Line	:	555 E CLAY ST
Second Line	:
City	:	EL PASO
State	:	IL
Zip	:	61738-1508
Country	:	US
Telephone Number	:	309-527-6240
Fax Number	:	309-527-6243

Authorized Official
Title or Position	:	SR. VP & CFO
Name	:	MR. DAVID M UNDERWOOD
Credential	:
Telephone Number	:	309-828-4361

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	04/06/2022

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