Provider Demographics
NPI:1598009128
Name:HERITAGE MANOR - BEARDSTOWN SOUTH, LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR - BEARDSTOWN SOUTH, LLC
Other - Org Name:HERITAGE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:309-823-7135
Mailing Address - Street 1:115 W JEFFERSON ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3946
Mailing Address - Country:US
Mailing Address - Phone:309-828-4361
Mailing Address - Fax:309-829-5477
Practice Address - Street 1:8306 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-8384
Practice Address - Country:US
Practice Address - Phone:217-323-4055
Practice Address - Fax:217-323-9454
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-20
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145952Medicare Oscar/Certification