Basic Information
Provider Information | |||||||||
NPI: | 1457343170 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HERITAGE MANOR BLOOMINGTON, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HERITAGE HEALTH - BLOOMINGTON | ||||||||
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: | 3098295477 | ||||||||
Practice Location | |||||||||
Address1: | 700 E WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IL | ||||||||
PostalCode: | 617013244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3098278004 | ||||||||
FaxNumber: | 3098270256 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2005 | ||||||||
LastUpdateDate: | 05/27/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
AuthorizedOfficialTelephone: | 3098284361 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HERITAGE ENTERPRISES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X |   | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   | 225XP0019X |   | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 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 |   | 332BX2000X | 48157 | IL | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 314000000X | 48157 | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.