Provider Demographics
NPI:1235127945
Name:NORTH ADAMS HOME INC
Entity Type:Organization
Organization Name:NORTH ADAMS HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LNHA
Authorized Official - Phone:217-936-2137
Mailing Address - Street 1:2259 E 1100TH ST
Mailing Address - Street 2:
Mailing Address - City:MENDON
Mailing Address - State:IL
Mailing Address - Zip Code:62351-2720
Mailing Address - Country:US
Mailing Address - Phone:217-936-2137
Mailing Address - Fax:217-936-3106
Practice Address - Street 1:2259 E 1100TH ST
Practice Address - Street 2:
Practice Address - City:MENDON
Practice Address - State:IL
Practice Address - Zip Code:62351-2720
Practice Address - Country:US
Practice Address - Phone:217-936-2137
Practice Address - Fax:217-936-3106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0020925314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0020925Medicaid
IL146035Medicare ID - Type UnspecifiedFEDERAL PROVIDER NUMBER
IL0020925Medicaid