Provider Demographics
NPI:1508857459
Name:HERITAGE MANOR GILLESPIE, LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR GILLESPIE, LLC
Other - Org Name:HERITAGE HEALTH - GILLESPIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR.VP & CFO
Authorized Official - Prefix:MR
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
Mailing Address - Street 2:SUITE 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 1:7588 STAUNTON RD
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-3232
Practice Address - Country:US
Practice Address - Phone:217-839-2171
Practice Address - Fax:217-839-1372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-31
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL048892314000000X
IL0048892332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========-801OtherMEDICAID OXYGEN PROVIDER
IL=========001Medicaid