Provider Demographics
NPI:1134126063
Name:DECATUR MANOR HEALTHCARE, LLC
Entity Type:Organization
Organization Name:DECATUR MANOR HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:847-675-7979
Mailing Address - Street 1:6840 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2628
Mailing Address - Country:US
Mailing Address - Phone:847-675-7979
Mailing Address - Fax:847-675-0555
Practice Address - Street 1:1016 W PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1541
Practice Address - Country:US
Practice Address - Phone:217-875-0833
Practice Address - Fax:217-875-6851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310500000X
IL0049262310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL612731133Medicaid
IL370969602Medicaid
IL31CX5Medicaid