Provider Demographics
NPI:1548412976
Name:BRETHREN HOME
Entity Type:Organization
Organization Name:BRETHREN HOME
Other - Org Name:PINECREST MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA NHA
Authorized Official - Phone:815-734-4103
Mailing Address - Street 1:414 S WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:61054-1428
Mailing Address - Country:US
Mailing Address - Phone:815-734-4103
Mailing Address - Fax:815-734-7318
Practice Address - Street 1:414 S WESLEY AVE
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:IL
Practice Address - Zip Code:61054-1428
Practice Address - Country:US
Practice Address - Phone:815-734-4103
Practice Address - Fax:815-734-7318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid