Provider Demographics
NPI:1457500621
Name:MONROE COUNTY
Entity Type:Organization
Organization Name:MONROE COUNTY
Other - Org Name:MAGNOLIA TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KECKRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-939-3488
Mailing Address - Street 1:623 HAMACHER STREET
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1598
Mailing Address - Country:US
Mailing Address - Phone:618-939-0500
Mailing Address - Fax:618-939-4906
Practice Address - Street 1:623 HAMACHER STREET
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1598
Practice Address - Country:US
Practice Address - Phone:618-939-0500
Practice Address - Fax:618-939-4906
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONROE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-12
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6229804Medicaid