Provider Demographics
NPI:1437329828
Name:DSI MANTENO OPERATOR LLC
Entity Type:Organization
Organization Name:DSI MANTENO OPERATOR LLC
Other - Org Name:HERITAGE WOODS OF MANTENO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAUGHTERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-932-1992
Mailing Address - Street 1:355 DIVERSATECH DR
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-9274
Mailing Address - Country:US
Mailing Address - Phone:815-468-3553
Mailing Address - Fax:815-468-3888
Practice Address - Street 1:355 DIVERSATECH DR
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-9274
Practice Address - Country:US
Practice Address - Phone:815-468-3553
Practice Address - Fax:815-468-3888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility