Provider Demographics
NPI:1154663946
Name:BRETHREN HOME
Entity Type:Organization
Organization Name:BRETHREN HOME
Other - Org Name:PINECREST MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FEROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LABASH
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:815-734-4103
Mailing Address - Street 1:414 S WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:61054-1428
Mailing Address - Country:US
Mailing Address - Phone:815-734-4103
Mailing Address - Fax:815-734-7318
Practice Address - Street 1:414 S WESLEY AVE
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:IL
Practice Address - Zip Code:61054-1428
Practice Address - Country:US
Practice Address - Phone:815-734-4103
Practice Address - Fax:815-734-7318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2038043OtherLICENSE NUMBER
145024Medicare Oscar/Certification