Basic Information
Provider Information | |||||||||
NPI: | 1699765719 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HERITAGE MANOR - GIBSON CITY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HERITAGE HEALTH - GIBSON CITY | ||||||||
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 E 1ST ST | ||||||||
Address2: |   | ||||||||
City: | GIBSON CITY | ||||||||
State: | IL | ||||||||
PostalCode: | 609361822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2177844257 | ||||||||
FaxNumber: | 2177848279 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2005 | ||||||||
LastUpdateDate: | 03/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | EXEC VP & CFO | ||||||||
AuthorizedOfficialTelephone: | 3098284361 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HERITAGE ENTERPRISES, INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 0048116 | IL | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 314000000X | 48116 | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.