Provider Demographics
NPI:1063659118
Name:FRIENDSHIP MANOR GROUP, LLC
Entity Type:Organization
Organization Name:FRIENDSHIP MANOR GROUP, LLC
Other - Org Name:FRIENDSHIP MANOR HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-327-3041
Mailing Address - Street 1:485 S FRIENDSHIP DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-1363
Mailing Address - Country:US
Mailing Address - Phone:618-327-3041
Mailing Address - Fax:618-327-4001
Practice Address - Street 1:485 S FRIENDSHIP DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1363
Practice Address - Country:US
Practice Address - Phone:618-327-3041
Practice Address - Fax:618-327-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0050161314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1508019548OtherLONG TERM CARE NPI #
IL=========001Medicaid