MEDICARE: HERITAGE MANOR - PANA, 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)

General Provider Information

NPI Number	:	1629312335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE MANOR - PANA, 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	:	309-829-5477

Provider Business Practice Location Address
First Line	:	1000 E 6TH ST
Second Line	:
City	:	PANA
State	:	IL
Zip	:	62557-1870
Country	:	US
Telephone Number	:	217-562-2174
Fax Number	:	217-562-7242

Authorized Official
Title or Position	:	SR VP & CFO
Name	:	DAVID M UNDERWOOD
Credential	:	CPA
Telephone Number	:	309-823-7135

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	04/24/2014

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