Provider Demographics
NPI:1568483329
Name:GOOD SAMARITAN NURSING HOME
Entity Type:Organization
Organization Name:GOOD SAMARITAN NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:RN ADMINISTRATOR
Authorized Official - Phone:309-289-2614
Mailing Address - Street 1:407 N HEBARD STREET
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61448
Mailing Address - Country:US
Mailing Address - Phone:309-289-2614
Mailing Address - Fax:309-289-8847
Practice Address - Street 1:407 N HEBARD STREET
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IL
Practice Address - Zip Code:61448
Practice Address - Country:US
Practice Address - Phone:309-289-2614
Practice Address - Fax:309-289-8847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001107Medicaid