Basic Information
| Provider Information | |||||||||
| NPI: | 1982695029 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERITAGE MANOR DWIGHT, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE HEALTH - DWIGHT | ||||||||
| 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: | 300 E MAZON AVE | ||||||||
| Address2: | |||||||||
| City: | DWIGHT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604201104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155841240 | ||||||||
| FaxNumber: | 8155841267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098284361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERITAGE ENTERPRISES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 50492 | IL | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 314000000X | 50492 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.