Provider Demographics
NPI:1669672465
Name:HERITAGE WOODS LLC
Entity Type:Organization
Organization Name:HERITAGE WOODS LLC
Other - Org Name:HERITAGE WOODS OF FLORA
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:ARTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS LCPC
Authorized Official - Phone:618-662-4599
Mailing Address - Street 1:1003 WEST 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839
Mailing Address - Country:US
Mailing Address - Phone:618-662-4599
Mailing Address - Fax:618-662-6179
Practice Address - Street 1:1003 WEST 4TH STREET
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839
Practice Address - Country:US
Practice Address - Phone:618-662-4599
Practice Address - Fax:618-662-6179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
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=========001Medicaid