Provider Demographics
NPI:1639513963
Name:LINCOLN TRAIL PLACE LIMITED PARTERNERSHIP
Entity Type:Organization
Organization Name:LINCOLN TRAIL PLACE LIMITED PARTERNERSHIP
Other - Org Name:HERITAGE WOODS OF CHARLESTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-345-4900
Mailing Address - Street 1:480 W POLK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3291
Mailing Address - Country:US
Mailing Address - Phone:217-345-4900
Mailing Address - Fax:217-345-4904
Practice Address - Street 1:480 W POLK AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-3291
Practice Address - Country:US
Practice Address - Phone:217-345-4900
Practice Address - Fax:217-345-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility