Basic Information
| Provider Information | |||||||||
| NPI: | 1396736351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERITAGE MANOR BEARDSTOWN SOUTH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE HEALTH - BEARDSTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 8306 SAINT LUKES DR | ||||||||
| Address2: | |||||||||
| City: | BEARDSTOWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626188384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173234055 | ||||||||
| FaxNumber: | 2173239454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098284361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE ENTERPRISES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 0048843 | IL | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 314000000X | 48843 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 205300208-001 | 05 | IL | MEDICAID | 205300208-801 | 01 | IL | MEDICAID OXYGEN PROVIDER NUMBER | OTHER |