Basic Information
Provider Information | |||||||||
NPI: | 1093706830 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HERITAGE MANOR - DANVILLE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COLONIAL MANOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 115 W JEFFERSON ST | ||||||||
Address2: | SUITE 401 | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IL | ||||||||
PostalCode: | 617013946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3098284361 | ||||||||
FaxNumber: | 3098299512 | ||||||||
Practice Location | |||||||||
Address1: | 620 WARRINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 618325446 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2174460660 | ||||||||
FaxNumber: | 2174469839 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2005 | ||||||||
LastUpdateDate: | 01/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR V.P. & CFO | ||||||||
AuthorizedOfficialTelephone: | 3098237135 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HERITAGE ENTERPRISES, INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X |   | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 224Z00000X |   | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   | 2251G0304X |   | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | 225200000X |   | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   | 235Z00000X |   | IL | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 314000000X | 0042168 | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.