Basic Information
| Provider Information | |||||||||
| NPI: | 1710156609 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE ENTERPRISES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVERGREEN PLACE SUPPORTIVE LIVING FACILITY | ||||||||
| 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: | 3098237155 | ||||||||
| FaxNumber: | 3098299512 | ||||||||
| Practice Location | |||||||||
| Address1: | 8570 SAINT LUKES DR | ||||||||
| Address2: | |||||||||
| City: | BEARDSTOWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626189200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173234055 | ||||||||
| FaxNumber: | 2173239454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2008 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | ATER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR V. P. OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3098237135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE MANOR - BEARDSTOWN SOUTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 1825445 | IL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.