Provider Demographics
NPI:1568669778
Name:HAWTHORNE INN SUPPORTIVE LIVING FACILITY
Entity Type:Organization
Organization Name:HAWTHORNE INN SUPPORTIVE LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WOOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-875-6600
Mailing Address - Street 1:136 N. SIXTH ST.
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356
Mailing Address - Country:US
Mailing Address - Phone:815-875-6600
Mailing Address - Fax:815-875-6005
Practice Address - Street 1:136 N. SIXTH ST.
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-875-6600
Practice Address - Fax:815-875-6005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL006310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid