Provider Demographics
NPI:1528398021
Name:HERITAGE WOODS OF DWIGHT, LLC
Entity Type:Organization
Organization Name:HERITAGE WOODS OF DWIGHT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-584-9280
Mailing Address - Street 1:701 E. MAZON AVE.
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420
Mailing Address - Country:US
Mailing Address - Phone:815-584-9280
Mailing Address - Fax:815-584-9283
Practice Address - Street 1:701 E MAZON AVE
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1124
Practice Address - Country:US
Practice Address - Phone:815-584-9280
Practice Address - Fax:815-584-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility