Provider Demographics
NPI:1629229414
Name:HERITAGE WOODS OF DEKALB
Entity Type:Organization
Organization Name:HERITAGE WOODS OF DEKALB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-787-6500
Mailing Address - Street 1:2626 N ANNIE GLIDDEN RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2626 N ANNIE GLIDDEN RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-1106
Practice Address - Country:US
Practice Address - Phone:815-787-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility