Provider Demographics
NPI:1477703882
Name:HERITAGE MANOR - CARLINVILLE, L.L.C.
Entity Type:Organization
Organization Name:HERITAGE MANOR - CARLINVILLE, L.L.C.
Other - Org Name:HERITAGE ENTERPRISES, INC DBA HERITAGE MANOR CARLINVILLE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SENIOR VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-4361
Mailing Address - Street 1:115 W JEFFERSON ST
Mailing Address - Street 2:STE 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 1:1200 UNIVERSITY AVENUE
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-9600
Practice Address - Country:US
Practice Address - Phone:217-854-4433
Practice Address - Fax:217-854-6291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-22
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370909086806OtherPRIOR MEDICAID OXYGEN PROVIDER #