Provider Demographics
NPI:1417943812
Name:RESTHAVE HOME OF WHITESIDE COUNTY ILLINOIS
Entity Type:Organization
Organization Name:RESTHAVE HOME OF WHITESIDE COUNTY ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:TEGELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-772-4021
Mailing Address - Street 1:408 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:IL
Mailing Address - Zip Code:61270-2936
Mailing Address - Country:US
Mailing Address - Phone:815-772-4021
Mailing Address - Fax:815-772-4583
Practice Address - Street 1:408 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:IL
Practice Address - Zip Code:61270-2936
Practice Address - Country:US
Practice Address - Phone:815-772-4021
Practice Address - Fax:815-772-4583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005785314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14E288Medicaid
ILIL6007884OtherFACILITY USER NAME