Basic Information
| Provider Information | |||||||||
| NPI: | 1376014969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE MANOR CHILLICOTHE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 W JEFFERSON ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617013967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098284361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1028 W HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615232258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092742194 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2018 | ||||||||
| LastUpdateDate: | 12/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098284361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE ENTERPRISES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
No ID Information.