Provider Demographics
NPI:1174512016
Name:COUNTY OF MCLEAN
Entity Type:Organization
Organization Name:COUNTY OF MCLEAN
Other - Org Name:MCLEAN COUNTY NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-888-5380
Mailing Address - Street 1:901 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1501
Mailing Address - Country:US
Mailing Address - Phone:309-888-5380
Mailing Address - Fax:309-454-4594
Practice Address - Street 1:901 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1501
Practice Address - Country:US
Practice Address - Phone:309-888-5380
Practice Address - Fax:309-454-4594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0018150314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0018150OtherSTATE LICENSE NUMBER
IL37600156801Medicaid
IL37600156801Medicaid
IL145494Medicare Oscar/Certification