Provider Demographics
NPI:1336138411
Name:GREENWOOD MANOR NURSING HOME INC
Entity Type:Organization
Organization Name:GREENWOOD MANOR NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:PLUMMER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:618-498-6427
Mailing Address - Street 1:410 FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2127
Mailing Address - Country:US
Mailing Address - Phone:618-498-6427
Mailing Address - Fax:618-639-3339
Practice Address - Street 1:410 FLETCHER ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2127
Practice Address - Country:US
Practice Address - Phone:618-498-6427
Practice Address - Fax:618-639-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0020206313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI4A111OtherIL DEPT OF PUBLIC HEALTH
ILI4A111OtherIL DEPT OF PUBLIC HEALTH
IL=========001Medicaid