Provider Demographics
NPI:1205827268
Name:HERITAGE MANOR - COLFAX, LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR - COLFAX, LLC
Other - Org Name:HERITAGE ENTERPRISES, INC. DBA HERITAGE MANOR - COLFAX
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXEC. VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
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 1:402 S HARRISON ST
Practice Address - Street 2:R.R. 2, BOX 56
Practice Address - City:COLFAX
Practice Address - State:IL
Practice Address - Zip Code:61728-7536
Practice Address - Country:US
Practice Address - Phone:309-723-2591
Practice Address - Fax:309-723-3013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2010-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL48140314000000X
IL0048140332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========-801OtherMEDICAID OXYGEN PROVIDER
IL=========-801OtherMEDICAID OXYGEN PROVIDER