Provider Demographics
NPI:1578757696
Name:HERITAGE WOODS OF BATAVIA I
Entity Type:Organization
Organization Name:HERITAGE WOODS OF BATAVIA I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:COPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-406-9440
Mailing Address - Street 1:1079 E WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2479
Mailing Address - Country:US
Mailing Address - Phone:630-406-9440
Mailing Address - Fax:630-406-9451
Practice Address - Street 1:1079 E WILSON ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2479
Practice Address - Country:US
Practice Address - Phone:630-406-9440
Practice Address - Fax:630-406-9451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6051001Medicaid