Provider Demographics
NPI:1225256696
Name:WOODSTOCK CHRISTIAN LIFE SERVICES
Entity Type:Organization
Organization Name:WOODSTOCK CHRISTIAN LIFE SERVICES
Other - Org Name:HEARTHSTONE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-338-9766
Mailing Address - Street 1:318 CHRISTIAN WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2912
Mailing Address - Country:US
Mailing Address - Phone:815-334-6200
Mailing Address - Fax:815-206-0472
Practice Address - Street 1:920 N SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2996
Practice Address - Country:US
Practice Address - Phone:815-334-6200
Practice Address - Fax:815-338-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL6009310314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6009310OtherFACILITY NUMBER
IL14A349OtherFEDERAL PROVIDER NUMBER
IL14A349OtherFEDERAL PROVIDER NUMBER
IL146015Medicare Oscar/Certification