MEDICARE: RANTOUL ESTATES, 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	305S00000X	Point of Service

General Provider Information

NPI Number	:	1700082377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANTOUL ESTATES, LLC

Provider Business Mailing Address
First Line	:	78 CENTENNIAL LOOP
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-7900
Country	:	US
Telephone Number	:	541-747-3373
Fax Number	:	541-747-0673

Provider Business Practice Location Address
First Line	:	300 TWIN LAKES DR
Second Line	:
City	:	RANTOUL
State	:	IL
Zip	:	61866-2663
Country	:	US
Telephone Number	:	217-892-5871
Fax Number	:	217-892-2128

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MR. JOHN HOLTZ
Credential	:
Telephone Number	:	541-747-3373

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	05/13/2008

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