Basic Information
| Provider Information | |||||||||
| NPI: | 1750372801 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERITAGE MANOR MINONK, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE HEALTH - MINONK | ||||||||
| 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: | 201 LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | MINONK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617601511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094322557 | ||||||||
| FaxNumber: | 3094323330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 06/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. V.P. & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098237135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE ENTERPRISES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 224Z00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 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 | 314000000X | 48058 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.