MEDICARE: ILLINOIS KNIGHTS TEMPLAR HOME

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	314000000X	Skilled Nursing Facility	0010058	IL

General Provider Information

NPI Number	:	1952308744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS KNIGHTS TEMPLAR HOME

Provider Business Mailing Address
First Line	:	450 E FULTON ST
Second Line	:
City	:	PAXTON
State	:	IL
Zip	:	60957-1716
Country	:	US
Telephone Number	:	217-379-2116
Fax Number	:	217-379-3000

Provider Business Practice Location Address
First Line	:	450 E FULTON ST
Second Line	:
City	:	PAXTON
State	:	IL
Zip	:	60957-1716
Country	:	US
Telephone Number	:	217-379-2116
Fax Number	:	217-379-3000

Authorized Official
Title or Position	:	CFO
Name	:	DAVID UNDERWOOD
Credential	:
Telephone Number	:	309-823-7135

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	08/07/2017

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Directions to “ILLINOIS KNIGHTS TEMPLAR HOME ” Practice Location

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