Basic Information
| Provider Information | |||||||||
| NPI: | 1932205713 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERRIN REHABILITATION AND NURSING CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILLOW OF HERRIN, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4213 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084262315 | ||||||||
| FaxNumber: | 7082360001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 N PARK AVE | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629482742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189422525 | ||||||||
| FaxNumber: | 6189881683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLISKO | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.F.O | ||||||||
| AuthorizedOfficialTelephone: | 7084262315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0040717 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.