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NPI Code Detail

MEDICARE: HERITAGE MANOR MENDOTA, LLC

MEDICARE: HERITAGE MANOR MENDOTA, 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
1332BX2000XOxygen Equipment & Supplies (DME)0048108IL
2314000000XSkilled Nursing Facility48108IL

General Provider Information

NPI Number : 1871583906
Entity Type Code : Organization
Provider Name (Legal Business Name) : HERITAGE MANOR MENDOTA, 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 : 1201 1ST AVE
Second Line :
City : MENDOTA
State : IL
Zip : 61342-1815
Country : US
Telephone Number : 815-539-6745
Fax Number : 815-538-2017
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 : 05/27/2014

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Directions to “HERITAGE MANOR MENDOTA, LLC ” Practice Location

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