Provider Demographics
NPI:1033354725
Name:KNOX COUNTY NURSING HOME
Entity Type:Organization
Organization Name:KNOX COUNTY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-289-2338
Mailing Address - Street 1:800 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61448-1096
Mailing Address - Country:US
Mailing Address - Phone:309-289-2338
Mailing Address - Fax:309-289-8384
Practice Address - Street 1:800 N MARKET ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IL
Practice Address - Zip Code:61448-1096
Practice Address - Country:US
Practice Address - Phone:309-289-2338
Practice Address - Fax:309-289-8384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0010561314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========801Medicaid