Basic Information
| Provider Information | |||||||||
| NPI: | 1376538157 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY & JANE VONDERLIETH LIVING CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE HENRY & JANE VONDERLIETH LIVING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 W JEFFERSON ST | ||||||||
| Address2: | STE 401 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617013967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098284361 | ||||||||
| FaxNumber: | 3098299512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 N TOPPER DR | ||||||||
| Address2: | |||||||||
| City: | MT PULASKI | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625481401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177923218 | ||||||||
| FaxNumber: | 2177923210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 05/30/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098237135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 19976 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.