Provider Demographics
NPI:1154454544
Name:CANTERBURY MANOR NURSING CENTER
Entity Type:Organization
Organization Name:CANTERBURY MANOR NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-549-8331
Mailing Address - Street 1:718 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1014
Mailing Address - Country:US
Mailing Address - Phone:618-939-8565
Mailing Address - Fax:618-939-3650
Practice Address - Street 1:718 N MARKET ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1014
Practice Address - Country:US
Practice Address - Phone:618-939-8565
Practice Address - Fax:618-939-3650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========801Medicaid
IL=========001Medicaid
IL=========801Medicaid