Provider Demographics
NPI:1093706137
Name:HERITAGE MANOR - EL PASO, LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR - EL PASO, LLC
Other - Org Name:HERITAGE HEALTH - EL PASO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-4361
Mailing Address - Street 1:115 W JEFFERSON ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3946
Mailing Address - Country:US
Mailing Address - Phone:309-828-4361
Mailing Address - Fax:309-829-9512
Practice Address - Street 1:555 E CLAY ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:IL
Practice Address - Zip Code:61738-1508
Practice Address - Country:US
Practice Address - Phone:309-527-6240
Practice Address - Fax:309-527-6243
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-28
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL48124314000000X
IL0048124332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2039003447-801OtherMEDICAID OXYGEN PROVIDER
IL=========001Medicaid
IL=========001Medicaid