Provider Demographics
NPI:1609076835
Name:DSI WATSEKA OPERATOR LLC
Entity Type:Organization
Organization Name:DSI WATSEKA OPERATOR LLC
Other - Org Name:HERITAGE WOODS OF WATSEKA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LEADER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:815-432-4560
Mailing Address - Street 1:577 E MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-2000
Mailing Address - Country:US
Mailing Address - Phone:815-432-4560
Mailing Address - Fax:815-432-4562
Practice Address - Street 1:577 E MARTIN AVE
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-2000
Practice Address - Country:US
Practice Address - Phone:815-432-4560
Practice Address - Fax:815-432-4562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility