Provider Demographics
NPI:1538289616
Name:REST HAVEN MANOR, INC.
Entity Type:Organization
Organization Name:REST HAVEN MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-445-2815
Mailing Address - Street 1:120 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:IL
Mailing Address - Zip Code:62806-1008
Mailing Address - Country:US
Mailing Address - Phone:618-445-2815
Mailing Address - Fax:618-445-3730
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:IL
Practice Address - Zip Code:62806-1008
Practice Address - Country:US
Practice Address - Phone:618-445-2815
Practice Address - Fax:618-445-3730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0013052313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid