Provider Demographics
NPI:1083602031
Name:HARBOR CREST HOME INC
Entity Type:Organization
Organization Name:HARBOR CREST HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHATTIC
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:815-589-3411
Mailing Address - Street 1:817 17TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:IL
Mailing Address - Zip Code:61252-1020
Mailing Address - Country:US
Mailing Address - Phone:815-589-3411
Mailing Address - Fax:815-589-4728
Practice Address - Street 1:817 17TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:IL
Practice Address - Zip Code:61252-1020
Practice Address - Country:US
Practice Address - Phone:815-589-3411
Practice Address - Fax:815-589-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0009530313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility