Provider Demographics
NPI:1376014969
Name:HERITAGE MANOR CHILLICOTHE, LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR CHILLICOTHE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
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 STE 401
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3967
Mailing Address - Country:US
Mailing Address - Phone:309-828-4361
Mailing Address - Fax:
Practice Address - Street 1:1028 W HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2258
Practice Address - Country:US
Practice Address - Phone:309-274-2194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-08
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies