Provider Demographics
NPI:1346230471
Name:HERITAGE MANOR STREATOR, LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR STREATOR, LLC
Other - Org Name:HERITAGE HEALTH - STREATOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:UNDERWOOD
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 1:1525 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-3162
Practice Address - Country:US
Practice Address - Phone:815-672-4516
Practice Address - Fax:815-672-5466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-28
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X, 2251G0304X, 225200000X, 225XP0019X, 235Z00000X
IL48066314000000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========-801OtherMEDICAID OXYGEN PROVIDER
IL=========-801OtherMEDICAID OXYGEN PROVIDER